Medical Report: 16-Year-Old Male Iraqi, Detainee, Abu Ghraib Prison, Baghdad, Iraq re: Gunshot Wound Pelvis and Arm

Medical report on a 16 year-old Iraqi male detainee from Abu Ghraib prison shot in the left hip and and arm with associated injuries. The medical records do not state how the detainee received his injuries and does not give any personal information on the detainee.

Doc_type: 
Physical (non-death)
Doc_date: 
Saturday, October 19, 2002
Doc_rel_date: 
Friday, October 14, 2005
Doc_text: 

7 1. Reporting MTF I 2. MTF Loc, _ Admission am9,ding Information I Fbr use of this form, see AR 40-400; the proponent agency is OTSG
IZ
0580 4. Pay Grade 5. Sex 3. Register Number Name (Last; First, Ml)
FGN M
111111.19(4)-14/111111011

9. Ethnicity Religion
6. DoB (YYYYMMDD) 7. Age at Admission 8. Race
Z 9

11. FMP 12. Social Security Number
10. Length of Service ETS
99

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allinall 19(t./
Branch / Corps:
13. Marital Status I Hour of Admission Z 20:23
Organization (Active Duty Only) 16. Zip Code of Residence:14. Flying Status 15. Beneficiary Category
K78-PRISONER OF WAR/INTERNEES 19. Trauma Prey. Admission
17. Unit Location 18. MOS
DIS NO

Name / Relationship of Emergency Addressee20. Source of Admission Ward:
Address of Emergency Addressee
ICW1
Direct from ER
Telephone Number of Emergency Addressee
Name and Location of Medical Treatment Facility:
0580 - 28th CSH - Iraq; No Install Provided

23. Date of Disposition (YYYYMMDD)
21. Type of Disposition 22. MTF Transferred To
2003-10-19

TRF-OTH 26. Date this Admission (YYYYMMDD)
24. Clinic Svc - Admitting 25. MTF Transferred From
2003-10-16

AEA - ORTHOPEDICS
--------•..N

29. Date of Initial Admission ,,-------"--
28. MTF of Initial Admission' 2003-10-16 27. Location of Occurrence
FOR LOCAL USE
Type Patient (Inpatient / Outpatient): Inpatient

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Admission Diagnosis Narrative: RIGHT ANKLE SPRAIN

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Procedure Narrative(s):
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Cause of Injury Narrative:
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of Admitting ClerkAdmitting Officer (Signature, as required
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Automated Facsimile - DA FORM 2985. MAR 2000
DOD-035217
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. Re ister N 2.9me9
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21. Source of Admission 22. Hour Of Adm:
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2003-10-19

30. Date Mit Adm 32. Units Blood Components
29. ReportingMTF
4580 9-2-2003-10-19

31. Selected Administrative Data
Marital Status:9 DoB:91988-03-01
In/Out Patient:9Inpatient9MOS:
33.
Cause Of Injury:

34.
Diagnosis / Operations and Special Procedures:

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O a° 11. b 59
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Absent Sick Days Other Days Co9v / Coop Care Days Supplemental9are Bed Days Total Sick Days
0 1h
35. Total Days This Facility
Absent Sick Days Other Days ConLv / Coop Care Days Supplemental Care d Days Total Sick Days
0
Signature of9 (icer Signature of PAD or Medical R cords Officer
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DATE SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry)
APO AE 09234 OPERATION IRAQI FREEDOM BAGHDAD, IRAQ

1 . OCT 2003 REASON FOR VISIT
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rlicWocti,on
REV. 5/1999) BACK
USAPA V1.00
MEDCOM - 216549IV) LO -1
DOD-035230
NSN 7540-01-075-378 6
TREATMENT FACILITYLOG NUM B7ER

EMERGENCY CARE AND TREATMENT
RECORDS MAINTAINED AT
MEDICAL RECORD
(Patient)
ARRIVAL PATIENT'S HOME ADDRESS OR DUTY STATION DATE (Day, Month, Year) TIME
I

STREET ADDRESS TRANSPORTATION TO FACILITY
STATE ZIP CODE CITY
THIRD PARTY INSURANCE

MILITARY STATUS9
DUTY/LOCAL PHONE YES I NO
ITEM9

SEX YES NO I N/A9
ITEM
AREA CODE ADDITIONAL INSURANCE

NUMBER
PRP

I
DD 2568 IN CHART
I9

FLYING STATUS9
HOME PHONE
AGE NAME OF INSURANCE COMPANY
is
MEDICAL HISTORY OBTAINED FROM
AREA CODE

NUMBER
I
EMERGENCY ROOM VISIT

INJURY OR OCCUPATIONAL ILLNESS
CURRENT MEDICATIONS

DATE LAST VISIT 124 HOUR RETURN
WHEN (Date)

N n NO
ITEM YES n YES TETANUS
WHERE

IS THIS AN INJURY?
--fib 0Cr\
COMPLETED INTITIAL SERIES INJURY/SAFETY FORMS
DATE LAST SHOT
.0 NO HOW O YES
...
CHIEF CoKL
L
( \ r‘9) VITAL SIGNS
CATE RY OF TREA MENT

TIM
EMERGENT

TIME
BP
291 1
PULSE

pc URGENT RESP
INITIALS
TEMP

I
U)
WT CXR PA & LAT/PORTABLE
NON-URGENT
C-SPINE

BHCG/URINE/BLOOD/QUANTPT PTT
CBC/DIFF ABG I9LS SPINE
-ACUTE ABDOMEN
CHEM:
Li., UA MSCC/CATH
, /URINE HEAD CT
URINE C&S
cc SINUS
cc BLOOD C&S X

0 X cc0 ANKLE R/L
ORDERS
n ECG

n MONITOR
91 PULSE OX 414 PATIENT'S RESPONSE
TIME

BY
ORDERS
TIME

bb c_ riPMligii
PATIENT/DISCHARGE INSTRUCTIONS
DISPOSITION QUARTERS /OFF DUTYDISPOSITION
n 24 HRS. n 48 HRS. n 78 HRS.
11 HOME n FULL DUTY
RETURN TO DUTYMODIFIED DUTY UNTIL TADMIT TO UNIT/SERVICE
REFERRED

CONDITION UPON RELEASE
UNCHANGED
TIME OF RELEASE

0 IMPROVED I have received and understand these instructions.
0 DETERIORATED
PATIENT'S SIGNATURE
(For typed or written entries, give: Name — last,
PATIENT'S IDENTIFICATION
first, middle; ID no. ISSN or other); hospital or
medical facility)

EMERGENCY CARE AND TREATMENT (Patient)
Medical Record

STANDARD FORM 558 (REV. 9-96)
Prescribed by GSA/ICSAR FPMR 141 CFR) 101•11.203(b)(10) USAPA V1.00
MEDCOM - 21655
DOD-035231

NSN 7540-01-075-3786
TIME SEEN BY PROVIDER

EMERGENCY CARE AND TREATMENTMEDICAL RECORD
(Doctor)
TEST RESULTS
Check if read by .
WBC ABG/PULSE OX RADIOLOGY radiologist

SUP 02 PH P02 RESULTS
H/H
2
co
PCO2 SAT OTHER
PLT DIP EKG INTERPRETATION
Fr
BHCG ETOH GLU MICROAPTT
PROVIDER HISTORY/PHYSICAL ,
R., vo 1 is o* Ltok) e?s\,-,) -}A g9• Pi-,i4i,

e_93
ZAA) . +‘)Ilti • 0-AA/All ec,..._,
tjk;_. 4.0 01, %1-
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P 6 : 05s , IpA AA0 x 3?
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ki)o-= .0 fri----1 Kiev—9E,-G) kJ #VO4 C6a19A.-0 131..coci
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Ni—V 1060--LOL S 1-i\-tfL ki DM°-
ACTION RESI ENT/MEDICAL STUDENT SIGNATURE AND STAMPCONSU T WITH TIME IDER SIGN
DIAGNOSIS
(For typed or written entries, give: me - last, first, middle;
PATIENT'S IDENTIFICATION
ID no. ISSN or other); hospital or medical facility)
EMERGENCY CARE AND TREATMENT (Doctor) Medical Record
STANDARD FORM 558 (REV. 9 -96)
Prescribed by GSA/ICMR FPMR (41 CFR) 101-11.203(b)(101 USAPA V1.00
MEDCOM - 21656
DOD-035232
PREOPERATIVE/POSTOPERATIVE NURSING DOCUMENT
MEDICAL RECORD
FOR Use this form. See AR 40.407: the Proponent agency is The Office of the Surgeon General.
2. KNOWN ALLERGIC SENSITIVITIES (e.g.. lodin, Tape, Medication)
1. AGE 15 1$1 NKDA . PCN . LATEX . 10DINE . TAPE . FOOD
REACTION:
HEIGHT:
WEIGHT:115 3. PREVIOUS SURGERY [y] NO [ ] YES (type):

4. PROPOSED SURGICAL PROCEDURE:
Tir S Ftrcel-Mcopq
a: b LI . Perymv9liaLti on 0•C Ex R)t•9 Guinc +
5. ADDITI NAL INFORMATION: (Previous surgical and medical history) Skin Condition 9 Tobacco9ppd X_____vrs Body Piercing 9Diabetes (Y)39ROM 9ASA/Motrin W 72hrs 018 ETON" Implants 9Respiratory Disease (Asthma COPD) (Y) a Anticoagulants (Y)ED
Glasses/ ontact (Y)(2) Dentures 9Hypertension (Y) (9 Herbal Medicines (Y) (N) MEDS:
6. PATIENT PROBLEMS AND NEEDS 7. PATIENT GOALS AND EXPECTED OUTCOMES 8. OR NURSING INTERVENTIONS
A. PSYCHOSOCIAL 4 . Allow pt. to verbalize freely.
)1 potential for anxiety related 4) Pt. verbalizes any specific anxiety.
9. Explain Or environment and answer to:, Pt. Exhibits relaxed body posture.
questions regarding surgery. 1) Surgical Procedure& (. Offer comfort measures. (e.g. warm Operating Room Environment blanket. touch). 2) Separation Anxiety
4). Explain all nursing procedures before Child
they are done. 93) Surgical Outcomes d. Remain with pt. Whenever possible.
I. Maintain family interface. Parents to stay with pt.
B. AERATION Potential for respiratory dysfunction due to:
1) Positioning
—7-2) Effects of Anesthesia

3) Medical/Smokingllislory
C. INTEGUMENT
I'
9Potential Impairment of Skin Integrity due to:
A 1) Intraopelam jrnm_Qmy
T
2) Es.U___Pi Pjactment 3) Positional Aids 4) Prosthesis y 95) Poling of arep3olutions
Pt. will be able to breath without difficulty during immediate intraoperative phase.
4t Pt. will exhibit signs of impairment of skin integrity (e.g., reddened areas).
q.

Offer to elevate head of litter or offer pillow.
9. Observe pt. While awaiting surgery for
signs of distress.
4). Assist anesthesia during intubatior
and extubation.

4). Utilize pressure preventing devices on OR table and accessories.
0. Check for proper positioning and
support to maintain good body alignment.

4. Pad pressure points.
9. Place ESU ground pad on non
compromised skin surface area.
Q. Keep prep fluids form pooling.

9. PATIENT'S IDENTIFICATION: ( For typed or written entries VERIFICATIONS AT HOLDING AREA: give: Name-last, first, middle; grade, data; hospital or medical facility) ! ID/Allergy Band ! Dentures Removed
I H & P ! Contacts Removed ! NPO Since ! Jewelry Removed
! UHCG/LMP ! Body Pierce Removed
ler 5-9a [,(()
! Consent/Blood Transfusion Signed/VVitnessed/Dated
! Surgical Site/Consent verified by Pt./Anesthesia/Surgeon
111111111116
! Contact precautions (Y) (N) ! Family/Friend:
4o C) 4tligh DA FORM 5179, JUN 91 Previous editions are obsolete. USAPA VI.0
MEDCOM - 21657
DOD-035233
6. PATIENT PROBLEMS AND NEEDS
. IRCULATION JA Potential for inadequate tissue
perkuision due to: A 1) Intraoperative Mobility
72) Positioning

3) Existing Disease

4) Safety Devices V 5) Hypothermia
E. NEUROMUSCULAR CONTROL
E.I. X Potential Impairment of Mobility due to:
1) Pain
, 2) Intra operative Hazzards
4( 3) prosthesis
4) Positioning
5) Transfer pt. To/form OR table

TF-7
Potential Discomfort Due to:
1) Length of Surgery
X 2) Positioning 3) Arthritis
F.9pecial Senses
F.I. X 9Diminished visual perception
due, to being: 1) pre-medicated
2) W 0 GLASSES
F.2. 9.4. Potential for Decreased
Communication due to: y 1) Diminished Hearing Y 2) Language Barrier
F.3. Potential Injury due to
Dentures:
4) Caps
1) Upper9
2) Lower95) Crowns
93) Bridges
G. OTHER PATIENT PROBLEMS NEEDS OR Continuation of Above problems/needs.
10. NUR GI ERV NTION COMPLE
7. PATIENT GOALS AND EXPECTED OUTCOMES
Cp. Pt. will exhibit signs of adequate tissue perfusion (e.g. color, warmth. pedal pulse.
pt. will be transferred to OR table without
difficultly.
p pt. will be not experience unnecessary
physical discomfort.

\- pt. will be made aware of surroundings

i
p ior to anesthesia induction.
pt. will be transferred safely to OR table.
pt. will be able to understand instructions.
Minimize danger of injury during intraop
period.

OTHER PATIENT GOALS AND EXPECTED
OUTCOMES. Or continuation of above goals and
outcomes.

8. OR NURSING INTERVENTIONS
O Check foe support stocking or ace warps. if none, check with doctors. 4) Check that safety straps are
correctly applied.
O Offer pillow for under knees.

O Place and take down legs from
stirrups with slow bilateral motion.
10 Check that rings and all body
piercing has been removed.

01) Have sufficient people available for
transfer.
9 Insure proper body alignment.
riD Allow patient to lie in position of
comfort while waiting for surgery.

(1) Offer support (i,e..pillows. Bath
towel. etc) for positioning.

p Introduce self. keep pt informed as to 'where he. she is and what is happening. p Inform pt. in which direction to move and assist if necessary.
Speak clearly andostTey.. O Address pt. from -V 1.TI Ur side. Validate pt.'s understanding of verbal
p
communication.
O Verify removal of dentures.

OTHER NURSING INTERVENTIONS
OR continuation of above Interventions.

0/ADDITIONAL INTRAOPERATIVE INTERVENTIONS NOTED.
OC ?DATE
t

cP-r )ftd
SKIN INTEGRI : Boyle Pad Site: a Clean and Dry . Red . N/A Dy.ES4ING DRY & INTACT:
11. POSTOPERATI9ALUATION :
Drowsy . Sleepy9. Intubated
LEVEL OF CONSCIO SNESS: . ABO
a MOVES ALL EXTREMITIES Moves Upper Extremities
LEVEL OF ACTIVIT :9
. Transferred to Litter With o spinal
12. PREOPERATI E EVALUATION9PREPARED BY 13. T OPERATIVE
BY OP /fin) TIME: 2115
DATE:

REVERS OF FORM 5179, JUN 91
MEDCOM - 21658
(IWN) EATHING EASY:
oto (N)
LUATION PREPARED

It)

USAPA V1.0
DOD-035234

I.9
I INTRAOPERATIVF"nCUMENT• MEDICAL RECORD""
For use of this form, see AR 40-407, the propone
y is the office of The Surgeon General.

I9-. -
1. PATIENT TRANSPORTED TO OPERATING N.9.9..,,9-2. PATIENT IDENTIF9REVIEWED AND PROgEDLIRE
VIA9tillev?BY ar/Po-fill&-iD VERIFIED BY9 CPT/AN 3, DATE9 TIME PATIENT ARRIVED IN SUITE 4.- PATIENT IN ROO
lq OCt 69 29_0 0 TIME 220D9 N MBER
5. PREOPERATIVE EMOTIONAL STATUS
• CALM Eil ANXIOUS9. EXCITED. • CRYING9• ANGRY . WITHDRAWN • OTHER (Specify)
COMMENTS:
lira bi.e -to speak ry. artterthand . Eryi lido
6. NURSING PERSONNEL
ASSIGNED ' -RELIEF
¦SPC9 ---­SCRUB ...SCRUB

ASSIGNED RELIEF
CIRCULATOR -...„_„..C.ISCULATOR

7. POSITION AND POSITIONAL AIDS (Specify) _..•,
n SUPINE9• LITHOTOMY
II PRONE 9III KRASKE: Z?LATERAL: U LEFT SIDE UP9• RIGHT SIDE UP •-..::9i:, •,:,
COMMENTS: propel, bocitA9,1"irrinfir)].. tyru
rt -9&Illy 1,1,11dp v914- . Iii p
8. SKIN PREPARATION. HAIR REMOVAL9¦ YES rI NO ' PREP IOLUTION (Specify) &td:I nc &,.4 -1.4 b I 60 0
DONE BY:9• OR • NURSING UNIT SITE: Kt. i..e99 BY WHOM: melei,-
METHOD:9• DEPILATORY ¦ RAZOR. SITE,.:.. . 9 BY WHOM:

• CLIP .9_ COMMENTS: ___----...COMMENTS:ND prtli no of Ftuiri c
9. LOCATION OF EXTERNAL DEVICES
,..,..„, -
-9.1',•::;::
-, - :----
",/,

I.
_

-IA „91 /. //V9l ;M;. GoVk . r.I
-AII'P:-I.
--"sliwaa"taleillimITIONP-
_ •
.9,

-11111# •
.., .:. .... . ,
610 - --'

LEGEND9X Ground Pad - Safety Strap9= = = TourniqUet:::;.:--
C = Correct9I = Incorrect "Ta iiai., --

First Closing Final Closing
10. COUNTS Other** Count ._ :I ,;:_; Cairn SCRUB
g"IIIIIMIFTOR Sponge9gig Yes Vo ._:.
Needle Sharp90 Yes Vo ..-.--... -
Instrument9. Yes No ..9..----. L•U.L.,;.11:,1.2,,,r, :7
.._ ...-.
Other9. Yes Vo
11. PATIENT IDENTIFICATION (For typed or written entries give: 12. ELECTROSURGERY DEVICE(S) (ESU) n. YES9. NOName - Last, first, middle; Grade; Date; Hospital or Medical Facility;)
MO le 4}-1 15g. ESU NO: Thretzio9RP),-61063as zi o4b
GROUND PAD: BRAND Vat !PI 17)6 eeln
... •..,_.: • •
%, 9
....,.._•

_9..., LOT NO:9IP la 2.4 5
15 --y o CY 9
' ItrA-.0•No:
',.-*•-.GFIOUND PAD: BRAND
• ._.,.,-
LOT NO:
1-Lia-ti99QUccui qS1 1-9
¦ BIPOLAR NO:

Gsw?-1-D?L -h-,;I•
9 9
-I, REPLACES DA USAPA V1.09
MEDCOM - 21659 IS OBSOLETE.
DOD-035235
13. PROSTHESIS, IMPLANTS 1 . . NO IF YES NAME: ID NUMB. ,NUFACTURER
. _9__„........

1/501% 1809pb-y,-X4,9
IloRrnan Tr Lead ''' (562_9 zoi
0 4..q4-Kgattic,;_gpvt., Itif-P WPMEDICATIONS/ORDERS i,,_ ,,,. . '
IRRIGATION/MEDICATIONS GIVEN IN OPERATING. ROOM (NOT BY ANESTHESIA) YES ¦9NO (MEDICATIONS/SOLUTION DOSAGE..... TIME' METHOD PREPARED BY GIVEN BY
MOUND IRRIGATION E YES 0 NO, TYPE(S):
,-

0.c1 pip NS
. ,

tOTHER ORDERS TIME CARRIED OUT BY
Non,
•4••
-9-9.-

HYSICIAN'S SIGNATURE
. , -,,

15.
X-RAY IN OPERATING ROOM IF YES, SITE

YES RI NO • C" Arlen9' LI 14-i p "

16.
- • f.:':iLABORATORY SPECIMENS

. •,..,

SPECIMEN (S) NAME • ____ ____..........----NAME
YES ¦9NO cgi . „
FROZEN SECTION (ES) NAME NAME
YES NO
¦9U
CULTURE (C) NAME NAME
YES ¦9NO _I ......9-—9-----
NAME NAME NAME
NAME NAME -18. DRESSING/IMMOBILIZATION (Specify)
. . _
17.9TUBES, DRAINS/PACKING9YES9Gir NO..W RURS
TYPE/SIZE 1. i 2. . , .

1 Q.A( 11' V,

/le. Pentrok,
SITE 1. 2. 3. .. . - ...,....--._ Abd
LI-, FtuntA,

19. ADDITIONAL INFORMATION -
Skilt, -' A
..--.1z.....i,..,,L-ill-. fee G-e_nevai
__._........9_ :

4sorve.x.
(0 -1._9._....... Fol-e-99plDce., -PT Pc
20. OPERATION(S) PERFORMED
11 , PrOe)()&-ON
. _ .
2. 1 ;, b 1-4-. cemav
3• Aercih?-ierN of Ex Fi

pp
21.
PATIENT TRANSFERRED TO\o 0 .. ..2/ TIME isnp-ND
Pct Uttei(

22.
ATURE

'

C T foi9MEDCOM - 21660
"
13CLICE1 "7-OT USAPA V1.00

DOD-035236
INTRAOPERATIVE nOCUMENT
MEDICAL RECORD --
' For use of this form, see AR 40-407, the propone =-. ' the office of The Surgeon General.
, .. • . 2. PATIENT IDENTIFIE D AND PROCEDURE
1. PATIENT TRANSPORTED TO OPERATING "1 BY iNif\e'SkirNela VERIFIED BY 1 LI
VIA 1,-.1 "tiQf
TIME PATIENT ARRIVED IN SUITE 4.• PATIENT)! ROO
i TIME., D159NUMBER
3. DATE
,------
‹9. OCT-D)
5. PREOPERATIVE EMOTIONAL ST US
fl ANXIOUS • EXCITED. • CRYING • GRY?• WITHDRAWN U OTHER (Specify)X CALM
COMMENTS: 12( C.4:5-vkx. Aivin, s vc.,‘ ,..,A.,9.
7-2/
0.

6. NU ING PERSONNEL
ASSIGNED G?.?7' " --RELIEF
SCRUB

"
.
CRT RELIEF

ASSIGNED
CIRCULATOR -

„..... . _ —.CIRCULATOR
_...,_
7. POSITION AND POSITIONAL AIDS (Specify)?
:?.?'':'-t•i: -?•

• LITHOTOMY • PRONE . _ • KRASKE, -LATERAL: • LEFT SIDE UP • RIGHT SIDE UP
K SUPINE
e

-(../tIm•c..c4-1,-, c7..re,./..c&-iv.„.u.„;;,;.1-4.---Lk•-...4:--4.-‘kc... 0,k I. 0..n.rw.,S %, r•n. ya_v_k_GLI— C"'0..dsrvapockpcks
COMMENTS: (›..ACVe_ PAGovv¦ 99k vo-zma-jcpr. QII?v-t•r.-4-(3k ot' 6...'" 4
8. SKIN PREPARATION
HAIR REMOVAL • YES jk] NO .?"-PRE:CLUTION (ppecifz)()A Y¦ . irk?

DONE BY: • OR • NURSING UNIT SIT 1...q_p( k-A.i j¦ BPakil SITE: : .,,. \ BY WHOM:
METHOD: • DEPILATORY • RAZOR • ".
U CLIP _ ....____.____L...2_
;-

COMMENTS: __.-----..COMMENTS: ^4.0, ,-(Am, iN.f-T..A,;" A'9Akc5.4..d.)
9. LOCATION OF EXTERNAL DEVICES
I. elririr
-

•111-"—"
-r-t"• ......."_...¦.._.4,-, 00.,._

I.-"
." Veraifir-
• •"•
."...

LEGEND X Ground Pad - Sa , Strap = = = Tourru , et...--•--c •.0
1.-, = Correct I = Incorrect

11,) kTk P‘ L
First Closing Final Closing
Other•• Count ...i,:::: Cdiint
10.COUNTS
...e.
nommon
Sponge FA Yes xilimt.
Needle Sharp Kl Yes lEirAlippr. .. ----,....... ,
Instrument Illi Yes la .:
Other • Yes FIA o V" Pir

11. PATIENT IDENTIFICATION For typed or written entries give: 12. .ELECTROSURGERY DEVICE(S) (ESU) • YES 14 NO
Name -Last, first, middle; Grade -Date; Hospital or Medical Facility;) -?•

\ICA-kk-t-110.--)s *OYU_ 40
.?....,?. IL ESU NO: GROUND PAD: -16 22 IFS — 2 CO-s—O-
1 BRAND No LOT NO: kk.. V.A.........- QieN.61.....a• biv-e -31 111111119 ()1-1-• :--:- _--- .
. :17:1,E_O NO:
..;:79
. -•• -,-rGROUND PAD: BRAND
, .•••,.._,

LOT NO:
moo bN--2_9
• BIPOLAR NO:

USAPA V1.00
DA FORM 5179-1, OCT 87 REPLACES!), :H IS OBSOLETE.
MEDCOM - 216619
DOD-035237
Cli NO IF YES NAME: ID NUMBE JUFACTURER .... __„-......
13. PROSTHESIS, IMPLANTS
'04. gr-,_ 4e-","m ' MEDICATIONS/ORDERS
islf ,9
IRRIGATION/MEDICATIONS GIVEN IN OPERATING. ROOM (NOT BY ANESTHESIA) YES • NO,
MEDICATIONS/SOLUTION DOSAGE;'... TIME . METHOD PREPARED BY GIVEN BY

..... ._.. . _
WOUND IRRIGATION tj YES / NO, TYPE(S): ...
. .

i O .9 °% 1CX. — R . s • 9
!OTHER ORDERS TIME CARRIED OUT BY khC51A-9—
.
'9
.9•9. „ s _ ...

fpl-IYSICIAN'S SIGNATURE
II
2........emosvonnanow,e,fa-v•vkw.v.,,-..,

15. X-RAY IN OPERATING ROOM IF YES, SITE
. :.:,:);
YES .11"NO tgj
16. - ' ' f ".'21.B0RATORY SPECIMENS
SPECIMEN (S)

NAME - .....,..__--NAME
.,____-_
YES • NO n
FROZEN SECTION (FS) NAME NAME

-...
YES • NO r,
CULTURE (C) NAME NAME

YES . NO
NAME NAME NAME

NAME NAME 18. DRESSING/IMMOBILIZATION (Specify)
17. TUBES, DRAINS/PACKING YES jz9NO • -Fitkits
-

TYPE/SIZE 1,31g cm 2.
'‘Agaiet VeAn.40 .
-e,..
SITE 1.,-..„, 2. 3. I--ct8e,
t...6, T-Cl.n.,,k,,,m

19. ADDITIONAL INFORMATION
.

s ' '•
SUf0/
•9:7,i'.2: :4f,;1

„ -9 _.,
_ 5 t--tc\ 6-y-19,0-9s
— NA911ct In ChAft /
20.
OPERATION(S) RFORMED

21.
PATIENT TRANSFERRED TO TIME 54...0..._, METHOD

P-kci x m -r3g9 1_i 9Jr-
22. TU RE
Ci9\--k9VV9MEDCOM - 21662
USAPA V1.00
DOD-035238

NSN 7540-00-62
MEDICAL RECORD -119 VITAL SIGNS RECORD
POST- HOSPITAL DAY DAY99.-e) (90" '0.10 1 21

DAY
MONTH-YEAR HOUR TEMP. C
19
TEMP. I=

PULSE 40.6°
(•)
(0)
131111%
105° 40.0° 104°
180 39.4° 0
°103
170 a)
0
38.9° a)

°1024—
160 a)
38.3 ° °101
150 37.8 °
a) °100
140 37.2 ° 37.0°
99° a)130
98.6° 36.7° • 120
98° 36.1° 110
97°
35.6 ° 100
96°
35.0 ° 90 95° 80
70
60


50 ... ... ...
40
RESPIRATION RECORD

M=M0661
MWMMMUMMIIIIM
BLOOD PRESSURE

)_7111112111
ii
lzr

WEIGHT
¦¦•• 11111111111EMIMINUIIIMII c41 •
HEIGHT:9GP+
"

1111111111.1MIIIENIMMIEM7011111.
111111111rra 1111111M111111111111.1111220112211MINIP*
4
a2A')

0
0.
CO

0
WARD NO.

cc0 REGISTER NO.
(For typed or written entries give: Name—last, first, middle; ID No.
PATIENT'S IDENTIFICATION
(SSN or other); hospital or medical facility)
a only when so ordered
VITAL SIGNS RECORDS Medical Record

STANDARD FORM 511 (REV. 7-95)
Prescribed by GSA/ICMR, FIRMR (41 CFR) 201-9.202:

MEDCOM - 21663
DOD-035239
MEDICAL RECORD VITAL SIGNS RECORD
HOSPITAL DAY POST-DAY MONTH-YEAR DAY
c)(4, 2-'7 e9b 21 3 e i
IP—kh Ai

HOUR l• I ?. 0?. .1. g . .c. U.". . i . 0.". ... . z.. TEMP. F
19
i890
Wz"cS).
*4)AS
,
i.". ."

:

.".
.g.
.

.9
. .9: . .9.
PULSE
.
...... ...,. 8,)". •o •

.
(0)
()
Is?•

105°
•• •• .. 180 104° ; ; , , ..
..
....

•• •• --•
•. . . . . .
" " ..
170 103°
. . . . .. .... . " " •• •• ..
. . . . .. . .... . : . : : : . •• : : : • • • • .. . . . . . . . . . . .
160 102°
....

. . . .
••• ' ....
"
" " " ••



•' ' •150 101°
......

...... •• •• • • • • -•
•• •• •• -•
......

0 . . .
. . .
......

140 100 . . v
.
71

.
gr. ""•. •."•. .
•.".".

: •."•. :"•. .•":
......



...... a

..
......
130 99° •
. . . 4p• . . • ?
al

• • ....,. . . . sly:
. .

98.6°
. .
'7••

. . ..... .,.
4"...
..... f



.

120
9NI
98° , •.
.
9
ntigrad

•• •• •-••
..
E.

. . .
.?.
.?- . V . :?•. :?: :?:
.?.
110 97° . •
?
. ..

.., .
. .. .. . . .

?d. .
"

% ?
.,' • • •


..

a?: .?.
.


96°
100
. . . . . .

. # . ' • • C). . .

42 • ••

. 0 • "

. . . . . . . .
.
. .
90
• "

95°
EJ

:
. .
. . .
• • ' •i •

• • .1

. . . . .
09•

. . . . . .
80
' "
. . •

. . . .
.

' " •'
. . . . . . . . . • . . .
70 "
.
•-• •• •
.
. .

.• •
At • •• • •• •• ••
: ...X .......

60 • " ' " "
• /I\

. .
....
• " •• •• " •• "
' ••
•• •• • . .
50 - • • . • . . A . . .
•• •• •• •• •• ••

--X •
h•9
.


....
t
•9•
. ..
••

1 ...,1
40
I '
. .

/
I
ei

.
ii. I
'2

RESPIRATION RECORD
BLOOD PRESSURE ,15.z !,....11 a!/5. go iiy,,
1214 'no. 11(1-70 an 7/ itzik 103 or, erp -al
9 171 • q(41.P Ci 7 VZ.
HEIGHT:91 WEIGHT --.....11).
qn
99 90 97'1 Q)2_5 Figireri. IP. 9#4219611,017 tri alta q-zi, 111?(?)RA RA o
'Record special data only when so ordered
PATIENT'S IDENTIFICATION (For typed or written entries give: Name—last, first, middle; ID No. REGISTER NO9 WARD NO.
(SSN or other); hospital or medical facility)
I
STANDARD FORM 511 (REV. 7-95) BACK

MEDCOM — 21664
DOD-035240

V LES ULT FORM I ..
(Subicet t,. the P
vaci..ote of 197-1)
SSW"
RESULT REF. RANGE

Wct
4.8-10.g x 10'
! 1.: 01 Or N/A
I RPR. Negative
7-. -7------19
i .e/.....11 N/A
e
1 . -. 09-a' Mono Negstive1 1
Giu Negative
PatiFt
—• . Iyacrobielagy .
. .

H
OC 12.1 H 4,s lor 5 Bili
Source
M L •Ve91.C.Z311
trO:i
H2b I Ket Negative
ii.V 1 2.0 Gram
Rtt 29.F
-:5:0 60,0 t -
Stain 30,0 ?9„9 'N/A
PI :77,1 :24.0
12ii 26.1 L Occ Bld Negative
31.1 1
Negative

Pit 317. H. pylori Negative
F,O. 50.
N/A

Micro Parasites Negative
Malaria
0.2-1.0
O &P
Negative

Other
Atyp

Imm
Negative

rascoi3k Urbil
RBC RAPJHLi

.AAI Yell ,. 14 .54 Negative
Morpl SER1A 1/1:1/03 21;41 'be 4-5
N\

Patient I

Spun
Test Name :PT

Hemat Blocxl.BiAk
Test Result:= 13.4 sec
• .9
Sed R2 Ratio = 1.1 .

Calculated INR = 1.16 MUST SUBMIT SF 518 WITH EVERY UNIT REQUESTED
Sample lype:citrated wh. blood
Other
Negative

Test Date :10/19/0 ABO/Rh
Test Time :21:39

Card Lot
cr6ssinitch' • Operator UBMIT SF,518. 1iVETEf.
yERy uprg OF BLOOD
REQUEST)
79;:
TYPE
CROSSA-L4TCif

RAPIDP

ANALYZER V4,54
SER1A

10/19/03 21:45

Patient ID

D dim
Test Name :APTT
Test Result:- 29.9

FDP ec.
Sample Type:citrat d wh. blood REM, Test Date :10/19 03 Test Time [R_E PC Card Lot LAB ID. NO.:. .
Operator

MEDCOM - 21665

DOD-035241

Warc.,"Stion: I REQUESTING PHYSICIAN:
. - I Cii EMLS TRY RESULT FORM i I (Sub-ect to the Privacy Act cf 1974) LAST, FMST, MI. 1. TINTE SSNRSEUDO SSN:

-4 Sq1(i.-ISTAT) .it i'.!.619)",eb4iiii:60.;:: -!,::: . (pioo1ogei4boi:::r4.60....
TEST RESULT REF. RANGE PF.V11T.T PPP, TEST RESULT REF. RANGE
).-i_.

Na 138-146 mmoi/L \O ( GL U 73-118 rogidl
K 3.5-4.9 mrnoVL: ....... ------ 7-22 meld)

BUN 19/10/03
Cl 98-109 mrnoL/L 21:16 CA' 8.0-10.3 rag/d1 REFERENCE RANGE:
pH -7.31-7M MALE CR.::-_,-: 0.6-1.2 mg/d1
PAT I ENT # :
)014
0-1

PCO2 35.45muog(kut. 128-145 mmol/1
41-51 rnm.,in (yen) GENERAL CFLN!SLR2i.NA' P02 80-losm.m4 (.1).7 3.3-4.7 mrnolt1
DISC LOT #:.

WA (veu1
OPER #:
00.

TCO2 23-27 mmo12 (rt) DR #:.CL: 98-108 mmol/1
24-29 mmowL (vca: SERIAL # HCO3 22-26 mmoVL (art) tCO2 18-33 mmo1/1
23-2S mrnoUL (vcn.
s02 95-98% ALB 3.8 3.3-5.5 G/DL
.'-':::::_,..:•'::.;(y4:cetili;:.¦)114iftrPArre1-Ifl0.0,?,•,Y
..,,T.._,,,,,,,,,„::,,JA-...,,,,7„..: 2::,..;•,,..;,:•(..,:.7,: •9.L..-.:„,:::,;-:-....,,i.:
ALP 195*.

26-84.

BEecf (-2) - (+3) U/L -TEST RESULT REF. RANGE
ALT 22.

10-47.

mrnol/L U/L
AnGap 10_10 mmovi., AMY 29 14-97 U/L ALB 3.3-5.5 01 Ca 1.12-1.32 nuno1/1 39* -U/L ALP 2644 u/1
AST 1138
0.6.

TBIL.0.2-1.6 MG/DL

BUN -8-26 mg./d1 ALT 10-47 u/I
7-22.GLU 70-105 mg,/d1 CA++.8.0-10.3 MG/DL.14-97 LA
BUN 5*.
MG/DL.

8.8.

AMY
100-200.Creat 0.7.
MG/DL..11-38 u/I
CHOL 78*.
MG/DL

0.7-4.5mWril CRE 0.6-1.2.AST GLU 123*.

73-118.TBIL
Hct -38-51% PCV MG/DL.0.2-1.6 img/d1
TP 6.7.
G/DL

6.4-8.1.

Hgb 12-17 g/e1.1 GGT 5_41.i lilt-....,
' ....-1 . — .1:4-niji ' . '''-1":'-':'.41; -'''''"*. : 2--; .f:::•,:.):::::4,-;',...‘..;• ,',­*, '; ••.., TEST _RESULT REF. RANGE I NST GC: HEM 1+ , OK LIP 0 CHEM GC : , ICT 0 OK ' • • ittig:6): e0friilYte:; •.:• -.1. :::-.;;.,i. • :-...-..,:. -i..-. - ,-; :::::,-- '
,......
Troponin-1 TEST RESULT REF. RANGE
Drug of NA' i ... ? 128­145 mmo1/1—
Abuse
. 3.3-4.7 mmo1/1
q r 11
CT . I 0 3 98-108 mrno1.1
tCO3 18-33 mmoL/1
.

REMARKS;
REPORTED BY: DATE: LAB ID NO.:
MEDCOM -21666
DOD-035242

MEDICAL RECORD - ANESTHESIA
For use of this form, see AR 40-66; the proponent agency is the OTSG
'ANESTHETIC AGENTS AND DRUGS
DRUG (Units) TOTALS TOTAL EBL
t-74Ak771 ,,V(, fr4f) ) /60 id(?,.. C I-if (51,0
. -9-6-0
kIA ,..,,D ,-t?I t.,-‘?) ?_L 4s0
lie.0,9p)-,t,?,.$J
2 1-) ?C)?(1,.;-Y / 1J
( --"-)

i(-17.--kro TOTAL URINE
too 0 •

(")
VOLAT 66-0 % del .-.D 2...5-"'. 2-D Z-. V Z- , 0 1 .D . FLUIDS • SUMMARY AGENT % e.t.
CRYSTALLOID-AIR L/Min Z..-C70 c)
N20 L/Min . COLLOID­
02 L/Min ----t--%-G a-2--a Z 7/2i
SINGLE DOSE DRUGS-MARK ON GRID .0„ BLOOD-
CONT INUO U S/REPEATEDD RUGS SPECI FY UNITS -MG/MCG/ML, "I" .CONSTANT INFUSION
WITH NUMBERS & ENTER IN REMARKS
LINE site . Warmed
REM K SEl Ram?.E Warmed £0D-,-'''''..----"--,../-.--. ..-//SC'D 9I 7(-D ?Code drugs with numbers,
to
.....""
events with letters

,126.1M0 . Warmed ...----. "'— ' -..--PC131 ?I :"()()
it.
. Warmed
EST BLOOD LOSS
LOSSES
URINE -PHYS STATUS
i.-G

TIME TO "".1°"
1 2 3 4 5 E
MEM

SYMBOLS: I
: : . : I9
BODY WEIGHT:
220
• KG BP by cuff
I9I I9I I9I
llGV9LB 200 , . , . „ , V • "
'

HEMATOCRIT: i"I
A no :9: '9:
"
, ,9.

Heart rate
160 " " "
"
INITIAL DATA: • ridiiiii.. ' " " '
IMP
Resp rate 140 wau, RI , „ , ,,
BP-
"/ HR-s EQUIP °KT- gb ECK N 120 100 8 t 60 BR (transduced)-L T TOURNIQUET M.ging1111•11iIIM N 9 Ed ,I=M. wireviTAIVIrEirwit. = EWE ma z ..,..ir dmeaimm=amar Aft MEM . . .",,". .
PATIENT RECHECK OK for PROCED T-,...f ANEs- X-X 40 2 NMI binatiiiii A"4IJ AV
PROC-0TIME - 7005— , -: : : : : M : : : : . . .
...i VT - ml max z6­0 376 KSE1 20 --z-z,
I— z ut Ci) Fr u, U)CD 41 0 4 C.) to CC f - breaths/min a' il I 7---•S -2___ Peak int pros / PEEP MODE -S1: on), A(sslst), C(on) . BP/Auto Cuff ET CO2 (torr) Fig WM WAIF M coupilMi 4 ( 7-gM1111. Mil , 7 IV •'7 .. . -7BP/oth F102 (Frac or %) ART line Sp02 (%) 'IL EMENEMMENIVIYAN _g_ /00 Mi _......_ 00 g A us • Eft,1 1 ISteth- PC/ES Gas analyzer ECG TEMP-site N -M Block (T/4) / D 6-til 4 1 RECOVERY AT CO/ 0 PACU ICU Specify) OTHER CONDITION; RESP-Sp02-BP -" HR -ANESTHESIA I PROCEDURE TIMES
I— 0 to w Start Room End
Z 0 E Warming blkt Cony warmer Mark with letters & symbols,?EVENTS...0. explain under REMARKS?Position? .... z --1"\ Ready(..) Begin0 ic: 22-1 0 ziLo 00e--0 End z.i.tor .

PROCEDURES and CPT Codes: ANESTHETIC TECHNIQUES: Describe block technique under Remarks
&e-3.T7
(C...)f---„,.,,,,_,1":7
PATIENT IDENTIFICATION: Typed or written entries: Name, Grade/Rate, grAcTx.MAIAG,E
,M$N4::2Antypralion routlade., ,,tecliniqx6e,":13_,,,,,,_ , , ,.-4-,,,,,
...k t -?
Medical facility i9'--""
6-7-cae, 7 v, (.2.-1,-/"7, 61
•a1111111 (0 (6) -1 /ei-r-, 7 2_,!,-.9_.•9C-0/..,:e ( 6-7-'30-
SURGEONS: ( JAOCEDURE ,,.,, 4 LOCATION: Li/C.. / _____ DATE: kn(6)'"1"
J T a (-;i P
PAGE

\ c..(-97-4246,i4V4. t OF 1
"
, FEB 1998 COPY 2 - ANESTHESIA PROVIDER9 USAPA V1.00
MEDCOM - 21667
DOD-035243

POCEDURAL ASSESSMENT (Sedatiog/Anesthesial Age DAYS MOS Sex (I-MALE ( ) FEMALE
Physi"tat 1"3 4 5 (E)

PROPOSED PROCEDURE: " INT: (.,C IN. SURGICAL SERVICE: " ALLERGIES:
I

NPO SINCE: "
HABITS: PREOPERATIVE
ASSESSMENT

TOBACCO: PAST MEDICAL HISTORY/SYSTEMS REVIEW
PAST SURGICAUANESTHETIC

ETOH: Cardiovascular:
DRUGS: Hypertension

Angina"N Y " CURRENT MEDICATIONS: MI"IN Y " ( ) = ordered as premed CVA"I N Y
Other
Pulmonary System:

() ()
Asthma Bronchitis/URI PHYSICAL EXAMINATION
()
( ) COPD BP1;IR"R _ T _ cfi
LO

Other Pain a 040
()
Renal System: HEENT - Teeth
0 Acute/Chronic RF Trachea PREMEDICATIONS: Gastrointestinal: TMJ/Neck None Yes Pit r-Hrs) /CC Hepatitis"N Y " Oropharnyx 1-1t.R...tmg IV IM PO Hiatal Hernia"N Y " Nares " mg N IM PO PUD/GERD"N Y " CHEST: C. 'T9t'S "mg IV IM PO Endocrine System: Diabetes"N Y " CARDIAC:
6-(?-

LABORATORY STUDIES: Steriods"N Y " Thyroid"N Y " EXTREMITIES: 1-113/HCT:"/ ' Neurological:
" Of

U/A: " Seizures"N Y IV Access: I of )-CAPS. OTHER: " Neuropathy Ulnar Filling: " Other"k N Gynecological : BACK: "
/2hy -251.1\ •
Pregnancy"N Y "
1 r

Other Significant Hx:/--\ OTHER: "
N
Familial HX
pt130 Since "
R.P6-e ag--
ANESTHETIC PLAN: { LOCAL { MAC"{ Regional (Specify): " General: Mask Intubation
INFORMED CONSENT/COUNSELING STATEMENT: Plans, alternatives and risks of anesthesia including death have been explained to and discussed with the patient/legal guardian.
The pati" nd a Questions answered.
?

Signed: mo o. ri"+-Time: Ai? t-t Hrs
9
POST-"EVALUATION AND NO"ON AS ) SEDATION KEY: { } NO ARENT ANESTHETIC COMPUCATI • S { OTHER
1.
MINIMAL (Anxiolysis) Patient responds normally to verbal commands

2.
MODERATE (conscious sedation)

Signed: " Date: Time:"Hrs
Patient responds purposefullyto verbal commands alone or accompanied by light tactile

Patient Identification: (Ward) "
stimulation. Airway assistance is not necessary.
3. DEEP SEDATION/ANALGESIA. Patient responds purposefully following repeated or painful stimulation. Airway assistance may be necessary.

NEV*) -ii
4. ANESTHESIA. Patient does not respond to painful stimulation.

WAMC Form 2300 (Revised) 15 Mar 01 mcicipos Previous edition is obsolete 'US. GPO: 2001-629.183/40002
MEDCOM - 216689:ORD
DOD-035244
MEDICAL RECORD ANESTHESIA
-

For use of this form, see AR 40-66; the proponent agency is the OTSG
/0 -
On

DRUG"(Units)
to (o TOTALS TOTAL EBL
0 0_1
0 Z
.2 tO I— Zin (94 0 1.-ujXi_ th O'3 o '3 8 (731:22 i_i-z 1, 2 1_ 0- • z w co 4 r•-l--I-CA 2 In 8D oz2 L- te 1­--OLZ If . ° co u i _ ( . ca ),.. _S' ...1 i ( )) (?a° ) VOLAT AGENT .,-,,,."% del —1-" % e.t. AIR L/fVlin N20 LiMin 02 L/Min ii= 70 C...'cm 1111 ImriwkirmratabAN In '2., 1/ W.1,¦ 111 It li I. g (Y‘rrj4C 7-0 TOTAL URINE 1 01-) 45-?50 FLUIDS - SUMMARY C RYSTALLOID--Z6 COLLOID-BIYd
z ,4 SINGLE DOSE DRUGS-MARK ON GRID WITH NUMBERS & ENTER IN REMARKS 1000-
to LINE site I R OUfl . Warmed 0 Warmed r.. "-0. ,,i MARKS Code drugs with numbers,
u- . Warmed OWarmed events with renters0 pit,"e4.2...
LOSSES EST BLOOD LOSS C. :=
WI NE-Sla YS STATUS TIME"40; 6---91.1-S—9109.-..91CY31?3 4 5"E SYMBOLS: , DY WEIGH 220 ' 11 tL CD . 2 V..L.41
r 0-HEMATOCRIT: BP by cuff ' , ' , eettat, d D0›8.4-4-301ti ) v 7 4 rev•Vic-,,,) ,", ' " ,
(transduced) • 1 B J!,1 :2) " H (,3c,Z E . . . , ,a i ia 1 , 100 111111MIUMEWIELWFAIIIIIIIIIMIll r"1 1"1 , , , 11 . 1 1 ,", 11 Il 1 • 11 I . , , , 1 • 1 ' , , , I 19, . I C. IYA (14.4.--tl-v-e-_-0, • coLtie..._to i , 0, 64 ( GL. -",1"Tir.01A igG""AC eD.0,c‘
O K?- 0 N ,
'
PATIENT9
0 PROCEDURE? TIME(OHO 17- PROC O^ (LIN f - breaths/min 20 lWaliblaillI „ I . ,. 1 11 1 ¦ . 1 II II I ' II I 11 1 1 19 : 11 I

Z w
Peak int pres / PEEP
/MODE -Slpon). (ssist), C(on)
RECOVERY AT It p

%., P/Auto Cuff ET CO2 (torr)
PACU ICU"Specify)

9
u-)BP/oth 02 (Frac or %)
CC ART line .02 (%) OTHER
0
to Steth• PC/ES CG
CONDITION:_

tn
La Gas analyzer EMP-sitellAin i
RESP- 7., Sp02 i C.) N-M Block (T/4) BP-f -579
.1 n- J
U) ANESTHE IA I PROCEDURE
cc TIMES
0
I.-vt?Start Room End
Z ..."--

(3 arming blkt 11 21111RMIMEIIIIIINIIIIMIlli to
4 po0 / D) 5 iiI)

2 Cony warmer 0 Ready Begin End
Mark with letters & symbols, EVENTS__,r6)
0

exple n under REMARKS Position?-
EI ozsinc-00

PROCEDURES and CPT Co
ANESTHETIC TECHNIQUES: Describe block technique under Remarks 41.4-0"irru,N.._"
PATIE T I ENTIFICATION: yped?i ).-L m a
written entries: Name, Grade/Rate, ?AIRWAY MANAGEM T: lntu
atio n route blade, technique, comments
Medical facility? .?14 (441/1 IFP S (A,,2A F-rCOL #663
PROCEDURE Ilia 4r11? tO(6)--2/ LOCATfON: DAT :
CO,20CfC)-3
E"

b (G) . ' 9 pill-PAGE ) OF )
rt A"res not w.•••••••-¦ ••¦ ,¦-•-¦ . a •¦. .. •¦ . • .
HESIA PROVIDER USAPA 81.00

MEDCOM - 21669
DOD-035245

irsi...L.Im.i11... rICLA—Irtl—1 — Lil; I UK'S'9
)ERS For use of this form, see MEDCOM Circular nfs 5
DIRECTIONS: The provider will DA19
, and SIGN each order or set of orders record
.

ne order is allowed per line. Nursing will the new order(sI are note,_ ..d initial in the column provided. Orders completes, _...mg the shift in which they were written do notlist the time
require recopying.
They may be signed off, as completed, in the far right column.
ORDER
ORDER NOTED COMPLETEDNUMBER DATE, TIME, & SIGNATURE REQUIRED FOR EACH ORDER OR SET OF ORDERS TIME & INITIALS TIME & INITIALS
POST ANESTHESIA ORDERS (circled Items)
VS q 5 min X 15 min, then q 15 min until discharge.
Su t• : ental oxygen.

3 Worphi - / Meperidirre 2—mg IV now and ---mg 4 3-5 min prn pain for a
max dose of /amg.
0 Zofran mg IV prn N/V q 15 min, may repeat x .

_
Metoclopramide mg IV prn N/V x 1.
6 Droperidol mg IV prn N/V x 1.
7 Phenergan mg IV prn N/V x I.

8
Benadryl 25-50mg IVP ql hr prn, itching while in PACU.
9 I -

@ /V-ac/hr.iftr _fie e m r- • -.tus when PACU discharge criteria met.

7
PATIENT IDENTIFICATION
Complete the following information on page 1 on y. Note any changes on subsequent pages. Diagnosis: 0 •
Height: Weight:
Diet: Allergies: Nur Unit Room No. Bed No. Page No.
1 of 1

-MAR 99 PREVIOUS ED T IONS ARE OBSOLETE
MC V1.00

MEDCOM - 21670
DOD-035246
MEDICAL RECORD - DOCTOR'S ORL"....
For use of this form, see MEDCOM Circular 40-5
DIRECTIONS: The provider will DATE, TIME, and SIGN each order or set of orders recorded. Only one order is allowed per line. Nursing will list the time the new orderls) are noted and initial in the column provided. Orders completed during the shift in which they were written do not require recopying. They may be signed off, as completed, in the far right column.
ORDER ORDER NOTED COMPLETED DATE, TIME, & SIGNATURE REQUIRED FOR EACH ORDER OR SET OF ORDERS
NUMBER TIME & INITIALS TIME & INITIALS
0 + Z7-1 7063 10(t-COST ANESTHESIA ORDERS (circled Items) 1 VS q 5 min X 15 min, then q 15 min until discharge. 2 Sup mental oxygen. Pgr3 ca_ 0-e_ C IS-?o 3 Morphin / Meperidine 'Z.-mg IV now and Z.--mg q 3-5 min pm pain for a lux ose of / 0 mg.
8
Zofran Li mg IV pm N/V q 15 min, nray-rupdt x
Metoclopramide 0 mg N pm N/V x 1.
Droperidol mg IV pm NN x 1.
Phenergan mg N pm N/V x 1.
Benadryl 25-50mg IVP ql hr pm, itching while in PACU.
1 IVF: L . e_ ® TKO-cc/hr.
10
Discharge from recovery status when PACU discharge criteria met.
g'

10
PATIENT IDENTIFICATION Complete the following information on page 1 only. Note any changes on subsequent pages.
Diagnosis:

Ianlapl
Height: Weight: Diet:
Allergies:
Nursing Unit Room No. Bed No. Page No.

loft

MEDCOM FORM 688-R (TEST) (MCHO) MAR 99 PREVIOUS EDITk:INS ARE OBSOLETE MC V1.00
MEDCOM - 21671
DOD-035247
CL1NiCAL RECORD - DOCTOR'S ORDERS
For use of this form, see AR 40.66, the proponent agency is OTSG
THE DOCTOR SHALL RECORD DATE, TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECORD
SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.

PATIENT IDENTIFICATION
DATE OF ORDER"
TIME OF ORDER LIST TIME
____aas?
NOTED ANDHOURS

1,N)A \ /41,.r Z1-1,?
SIG N

1
/--
4,
k 6-„,r.,61

15 "Ap 0 Aauk
A Ices.4,-2,q9A-...i ----93-1-02)Z.C.
4P:it9IP
V—
-Q C-ri "1-
"NURSING UNIT ROOM NO. O ..------
. 0 kleb41251¦"CAA?‹vMdk 720 (i\-1 I C3 IA ic-reig-41.4-v p,2r--)-
PATIENT IDE"IFICATION DATE OF ORDER"§
TIME OF ORD R",
j .711 -1.02 ?4.1" 12c ee, /912 10UFelA71 Ze56
.\\
,...7-,),2,

)4,, g2 "0) Wait
11.1\1kS.)
if c,3‹..?AN,?4li 11,-*
419 „oizoscoi ",-."p,z)._ 0 9-.‘i-At pi
242.- t(46?IP /;-SOLd• - 4:‹ #3 6-1 V?i 17)?1`74,1
6 47Z2(-d- M?2) i-,ze yi/
NURSING UNIT ROOM NO. ED NO. /
)0

4)1 4 1,—)"i14- Ain9?a .e-..)72-5Y‹./i) .-.0J.4. JV "O 'CV .
/ 4?-41 Alk"s --
PATIENT IDENTIFICATION DATE OF ORDER"TIME OF ORDER
t
/ 1/pg ci--/-dr Ca21--" /•P cerVol(P9e:17-.6
d 09t/-x. to cAL e 0 0-c J .b---/
act °
(21 2.00
NURSING UNIT ROOM NO.
BED NO.
LON -

PATIENT IDENTIFICATION DATE OF 0 DER"TIME OF ORDER
HOURS

NURSING UNIT ROOM NO.
BED NO.
REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED.
DA 4256
1 FAOP R
M79
MEDCOM - 21672
DOD-035248
CLINICAL RECORD - DOCTOR'S ORDERS
For use of this form, see AR 40-66, the proponent agency is OTSG
THE DOCTOR SHALL RECORD DATE, TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECORD SYSTEM IS USED, WRITE PROBLEM NU ER IN COLUMN INDICATED BY ARROW BELOW.
PATIENT IDENTIFICATION DATE OF ORDER" TIME OF ORDER LIST TIME ORDER NOTED AND
HOURS

"SIGN l am'
,oe--' .a , ///D"
1 ,..0
or 40.4 G. bi-,943-?j.6?) c2.1?k-,22 , . l L:5— 2 - 2; 12- 19 (t)--2--/.7.--9. 2- - - '"7-r'.e./Z ,/i/ Wb2-4-
? - "
It - -- •-•- /NURSING UNIT ROOM NO. BED"0.
J1 4I¦ ...-
0 L.A., ......,,e-X J /_.. 1 .
.. 2e... 111, Air
-.... .....
PATIENT IDENTIFICATION TIME 0"
'-- ' • ER

-\ r
li 0 -HOURS
25J
ii ,e.,1.4 r'd

NURSING UNIT ROOM NO. BE • NO. b (2)-
PATIENT IDENTIFICATION DATE OF ORDER" TIME OF OR • R"_6
_ 2._
HOURS

NURSING UNIT ROOM NO. BED NO.
PATIENT IDENTIFICATION DATE OF ORDER" TIME OF ORDER
HOURS

NURSING UNIT ROOM NO. BED NO.

REPLACI ICH MAY BE USED
DA FAOPR
M79 4256 MEDCOM - 21673
DOD-035249
THERAPEUTIC DOCUMENTATION CARE PLAN ( NON -MEDICATION)
CLINICAL RECORD For use of this form. see AR 40-407;
MO. I 1 Yr."2003

the proponent agency Is the Office of The Surgeon General.
VERIFY BY INITIALING INITIAL PROPER COLUMN FOLLOWING EACH COMPLETION
:0411-,,,A-4.stowseitsma
HR DATE COMPLETED
ORDER CLERK/ RECURRING ACTION, DATE NURSE FREQUENCY, TIME
0 WA 0 I - -ClS OG 0-1-C2t9 ( C-45 (( (2_13 ii-
1 ...,
al
oc.. IIIIIII\8 01 8nFt 4411
-
git
icf --IIIIIIr__,1 coE3 .(_D Coal r Cb .
P •••
19 - --iircala-di ,c-9e•, is
g.

(°i 111,11to ci-c_ c'e. eib
- Pil
..
1:,
(9On ,ai ocrOSS)
ALLERGIES:"MI YES NM NO PRIMARY DIAGNOSIS: ADDITIONAL PAGES IN USE: OpkEs MN No
Sip9-Fce_mce____ /.- F-1
PAGE NO' 2--

PATIENT IDENTIFICATION:
ACTION TIMES S U E PENCIL. CIRCLE ACTION TIMES MP 19 (C)-1"
D 8 9"
10"11"12"13 14"15 E"16"17 18"19"20"21"22"23 N"24 01 02 03"04 05 06 07
"
EDITION OF 1 DEC 77 MAY BE USED. " USAPA V1.00
DA FORM 4677, 1 OCT 78
MEDCOM - 21674
DOD-035250
CLINICAL RECORD I THERAPEUTIC DOCUFIMAthTeInCeAFAI 40-407; WON-MEDICATIO1V) T ,_,
T. 2003
,,,....ksp .the9r9anent aaencv Is the Office of The Suraeon General. 9Mdf...X., rY1
VERIFY BY IN717AL1NG z.a. 9,-.;!ig:w.4?..,,..,0;:,44.,--l-r-9
LVITIAL PROPER COLUMN FOLLOWING EACH COMPLETION
ORDER9CLERK/ RECURRING ACTIONS, HR9 DATE COMPLETED
DATE9NURSE9FREQUENCY, TIME9

PI9J._9e Al9. LI9• Y3
107 our VIII - V 59CI75h( (09I 9
1

)q OCi- Olt Taed res 1- 1 0 61q -1-ri913 14.
t 1'

9clei4 ir9-7- Z D9
Or*

11 GU- - 11111 ' ?-1t:5-,16 r-9
Die-491 s-17 nce
11 OCA-Ilk " Ft rt 014e ca,r.e.9in.Ly )0 "vai
9\51 r--)9Al09C.-÷ C) 3 I

.9 .

• ALLERGIES:9- YES9ill NO9PRIMARY DIA9SIS:9•9
ADDITIONAL PAGES IN USE: .YES91111 NO

-931109
i-E-07(4rL PATIENT IDENTIFICATION: - 1--, _Lx,9PAGE NC/• 9
• ACTION TIMES
MK t( ..c) -if9 USE PENCIL. CIRCLE ACTION TIMES
D9899910 11912 13 14 15
E916 17 18 19 20 21922 23
N924 01 02 03 04 05 06 07
DA FOVIRA 'LA77 I ACT 70
USAPA V1.00
MEDCOM - 21675

DOD-035251

Verit , by THERAPEUTIC DOCUMENTATION CARE PLAN
IES --2--
Initiating (NON-MEDICATIO1V) Mo_OC 7 Yr 2003
Order Date Clerk Nurse SINGLE ACTIONS Date to be Done Time to be Done Time Done Initials
110a-1111 Condi )(J)-)?3+-c. b)e 1 1 6q-- 0130
iticel C6 C._ r-i\I?74-tc)--) (20 Cott 056f). v5115
1) .0V ,------? re 0/1/1A 'Ci.0 A— .2A 51. CS s . _ _

. ...... _9_
.
..

.9. .
.
Order/ clerk/
PRN DIMAL PROPER COLUMN FOILOWING COMPLETION Date Nu". ACTION, FREQUENCY
TIMEIDATE COMPLETED
. • .
.
"m"—„' USAPA V1.00

MEDCOM - 21676
DOD-035252

.
THERAPEUTIC DOCUMENTATION
CLINICAL RECORD CARE PLAN (MEDICATIONS)
For useof this forms, ee AR 4040 ; u rgeon General.
the proponent a ncy is the Offic e of The S ModaYr. 2CEJ: VERIFY BY INITIALING ..
INITIAL PROPER COLUMN FOLLOWING EACH ADAHNISTRATION
ORDER CLERK/ RECURRING MEDICATIONS, HR DATE DISPENSED
DATE NURSE DOSE, FREQUENCY r

MO22-

Eriganrinenn
ion cc-I# r-a ti'.c." I q 0 c4-1111-T V L-r2.-p A-arcc I ti rt. 68
9)--ki0(0 cfr.9ii-Jh c 1---) t V
(0

-9-9--7-4(Crr1)9PO Vei/
X NEN milan...1 ......I..II==Ng m•ININ 110(4 -ig-iiice.?--r?5 ,,, 141913 nq / ?0 5? hrs /2-7 I
III /
II

tq oc-1-0-Ge--r.-4-c rei9c. r\ ?59) 10
I

Iv 49 15 9eDV)
? -Mal 111 RI
• _. _ -!.a":4"r aa.9V P fib IIIIII IIMi . MIH. 0MIMI=MNMIE-•
.CZ) P5k )(5 1 t:, cm?
II
2..ii

ALL, ERGIES^ El YES
Ei NO PRIMARY DIAGNOSIS:.
ADDITIONAL PAGES IN USEtD YES 0
NO

3/ PEThcfrt. 3-A y.
PAGE NOPATIENT IDENTIFICATIONt

DISPENSING TIMES USE PENCIL. CIRCLE MED TINES
(OH
D 7 8 9 10 11 12 13 14 E 15 16 17 18 19 20 21
22

N 23 24 01 02 03 04 05 06
P1 A"FORM • relas
DITION 0
I FEB79 MEDCOM - 21677 " .EXHAUSTED.
DOD-035253
Verify by THERAPEUTIC DOCUMENTATION CARE PLAN
3

Initialing (MEDICATIONS) Mo. Yr 0 1
Dote to Time to SINGLE ORDER, PRE-OPERATIVES Time Given Initials
Order Clerk/
Date Nurse be Given be Given
1
IP"--
Order/ Espir Date lq 6Ct Clerk/ Num PRN EDICATION, DOSE, FRE ¦ U erCO CGTA CY
.A 40 d

t9-'11111
..:,-4 .ill
...6,
1-•tiek-tol960 ri-G\9DD Po Qqinrs?N)-'
0 3 °
ik.'"—
-I-V r?Q 1 h r?1
619
INITIAL PROPER COLUMN FOLLOWING ADMINISTRATION
T1ME/0ATE DISPENSED
'"‘
'*

...,

1F,'""1
,r1 itit5

Pag Okw
D/...1. MIF11"1611°.
-

•9oe.
Pe. , c?Le1-.2...?P 0 7 Zept1, 2q..?,,?0
-,,--1-?,9 Y-4 hr--. P9
•91 Wo?15 1?N i
p
la
,--iX1-4" /‘' a3CCE1/1X P-' 06' nal). ' tts.-...
I.0 If

05 ditlif .7c° o3w i1 c° ?,#' -4,
A .• '1 .

lillig" a
TYN If. (At
'U.S. GPO: 1998454-110/95216

MEDCOM - 21678
DOD-035254
THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS)
CLINICAL RECORD
For use of this form, see AR 40-407;
the proponent agency is the Office of The Surgeon General. Mo._1(_Yr.13
1

VERIFY BY INITIALING INITIAL PROPER COLUMN FOLLOWING EACH ADMINISTRATION
ORDER CLERK/ HR"
RECURRING MEDICATIONS,
DATE DISPENSED
DATE"NURSE DOSE, FREQUENCY
(-1 V43511 (2
. *15-1-9
ru-rp?-R,
9
r mr; are St :b rk'n 1
Qff) Cif

1111111VC`CC9
‘("
t9

ALLERGIES-
YES ID NO PRIMARY DIAGNOSIS: ADDITIONAL PAGES IN USE: Y ES Q NO
S/p F
PAGE NO.

PATIENT IDENTIFICATION:
DISPENSING TIMES USE PENCIL. CIRCLE MED TIMES
WIN _6(09
D 7 8"9 10 11 12 13 14 E 15 16 17 18 19 20 21
22 N 23 24 01 02 03 04 05 06DA i FFOEFIV1 9 4678
EDITION OF 1 DEC 77 WILL BE USED UNTIL EXHAUSTED.
MEDCOM - 21679
DOD-035255
Verify by THERAPEUTIC DOCUMENTATION CARE PLAN 1.(MEDICATIONS) Mo..Yr (75
Initialing
Date to Time to
Order Clerk/
Time Given Initials

SINGLE ORDER, PRE-OPERATIVES
be Given be Given
Date Nurse
INITIAL PROPER COLUMN FOLLOWING ADMINISTRATION
Order/ Clerk/ PRN
Expir
Nurse DILATION, DOSE, FREQUENCY TIME/DATE DISPENSED
Date ,i•V--I\Did 0-CC:COI \-2—C::) cy-k---
V`(1 fi 11b
.9
,9
(4:sliN-n pO cA
9PPTO
?rn
I .,--
U.S. GPO: 1998-454410/S5216

MEDCOM - 21680
DOD-035256

MEDICAL RECORD•SUPPLEMENTAL MEDICAL DATA
For use of this Item. see AR 40.66; the proponent agency is the Office ol The Surgeon General.
OTSG APPROVED Wald

REPORT TITLE Post-Anesthesia Care Unit (PACU) Flow Sheet Anesthesia Type (Circle)):^
e pinal Epidural
Date:
IV Sedation AIOFve Block
Time In: Allergies: Pre-op VIS: Procedur _: OR Intake: Crystalloid "0 OR Output: UOP 10c7k--) V1,Meds/Times: f"IN , Colloid BL T-tube Foley
TLS
Pre Op Me Time sWiq Histor Time Solution Pacu Intake Amount Site • By Infused
Sa02
Fi02" //
Methods (tr iFs e
240

. Labs: 220 Post-Anesthesia Recovery score
ADM 30' D/C Codes
X-rays:
Criteria
200
Activity AIRWAY
(2)
Moves 4 Extremities

B B.mu b y2.......„ A=ABi obw-

(1)
Moves 2 Extremities ''-2 -

180
(0)
Moves 0 Extremities M = Mask. ­

Airway FT= Face 160 V (2) Cough, Deep breath Tent
__ --2__
(1) Dyspnea, limited breathing
V-V RA =RoornAlr
(o) Apnea
NC =Nasal

140
Blood Pressure Cannula
'

(2) SBP 4-20 of Pre-op
• (1) SBP -4-20-50 of Pre-op 2— 2, ws
120 2---
(0) SBP ./- 50 of Pre-op

X = A-line BP Consciousness ' =Cuff BP --
100 (2) Fully Awake, audible
=Pulse crYill9
A AA -12,...,,,
(t) Arousable to verbal or pain '..2.-----­TEMP
80
Color S =Skin
(2) Baseline color A appearance
0 = Oral

(1) pale, mottled. jaundiced
60 2...., (-2....k = Axillary
(0) Cyanotic
T = Tympanic

Circulation (Peds 5 Years) R = Rectal 40 radial Pulse Palpable
(1)
Axillary palpable, not radial

LOS

(0)
Carotid only reliable pulse

C = Cervical

20
TOTALS: Must be 9 or . T = Thoracic
greater to DIC. otherwise L = Lumbar
needs anesthesia approval for I-0 )0
RR '2‘) S = Sacral DIC.
Patient teaching done: Wound Care. Pain Management.
Time
T. C. & DB,. Incentive Spirometer, Comfort MeasuresPain (0-10)
Safety: SR up X 2. Falls Precautions. Privacy Maintained
LOS Il.onlmue on reversel
DATE
DEPARTMENTISERVICEJCUNIC

PREPARED BY
oc---ro 3
kA

PATIENT'S IDE entries give: Name -last, FLOW CHART
first middle: grade; date; hospital Of medical lace . HISTORYIPHYSICAL .
. OTHER EXAMINATION . OTHER ifrow/r/ OR EVALUATION
DIAGNOSTIC STUDIES
.

s't°f •
TREATMENT
.
Previous edition is obsolete

WAMC OP 173-E, (Revised) 1 Apr 01 (MCXC-DN)
DA FORM 4700, MAY 78 USAITC V2.00
MEDCOM - 21681
DOD-035257

MEDICATIONS
NURSING NOTES

Allergies: Time Pain Medication & Route Pain I/E By
1-10 Dosane 1-10 I SDI 0 92 r o?-6 L-Vd e+ pAtr4w`)cd,
--ro9'0)0k,L-L4(2-
NEUROVASCULAR
Time Site Range Sensory P Cap T Color
Of Refill
Motion

Adm
Lnsdlid '9" P V5 () 15' ( m •-ird 1 LJ
30' ( — ryl-i 9 ?- - t-d --P l' ,6 1,,/ P1( 45'
60'
90'
DSC
(1--Vel)W-P 6-3,-Ird?-V p 6 1,-/ Plj Movement/Sensation: + = present,- =absent Temp:C = Cool, W =Warm Pulses: P = Palpable, D =Doppler, A= Absent Color: C = Cyanotic, Capillary Refill: B = Brisk, S=S uggish P= Pale, Pk = Pink
C-SECTIONS
—Adm 15' 30' 45' 60' 90' DIC
Fund. Height
---....„...„._ Lochia • -...___..........._
Peripad# ----....,......._
Fund. Cond.
DRESSINGS
Location Type Drainage

Time
Adm 1 41.144.1., 0 ...AA/ . ' . '"• ..61Ar.,"1 30' 10,71M111KMIM I L...Ifall 41 /
60'
DIC Amt..flirt .¦.:' 6 el Lira

PACU OUTPUT
Time Source " Color/Appearance Amount Discharge Criteria: Date•2bLY--1-Time 01 66 PARS I L) BP: 11-14 /4 T:95-3 HR: 1-()2. RR: Sa02: Qg Pain Level at D/C (0-10):" Intake: 326-9Output: Additional Data:
CARDIAC RHYTHM
Transferred To: 1t._\,,)
Time _Rhythm Symptomatic? Rhythm Strip Run? Report Given To:

' S (2--hio K.,...k_ Transferred Via: W/C
Transferred By:
Cleared IAW Recovery
Charge Nurse Signature

TT S
WAMC OP 173-E
MEDCOM - 21682
DOD-035258

MEDICAL RECORD•SUPPLEMENTAL MEDICAL DATA
For use of this tom see AR 40-66; the proponent agency is the Office of The Surgeon General.
I
OTSG APPROVED Mare/

REPORT TITLE Post-Anesthesia Care Unit (PACU) Flow Sheet
Drains Airway

Anesthesia Type (Circle)): enera pinal Epidural IV Sedation Nerve Block
Date: oaf Oct- 03 &3'S •
Hemova Nasa Time In: "1114 Allergies: impel 114 OR Intake: Crystalloid 2,,bD Colloid NG Or
EBL
Pre-op VIS: Pr OR Output: UOP '50
tube Trach

Meds/Times: ISO•srl" /1,4 504Procedures: "L
oley
Other
IL

History
Pre Op Meds
Pacu Intake
Time
Time Solution Amount Site • By Infused Sa02 eft 14 '11
F102
Methods
1* to tt
240 . Labs:
X-rays:
220 Post-Anesthesia Recovery score
ADM 30' DIC Codes
200

Criteria
Activity
AIRWAY

(2)
Moves 4 Extremities

ds A =-- Arnim

(1)
Moves 2 Extremities

180 BB= Blow-by
(0) Moves 0 Extremities ..s. M — Mask
Airway FT = Face
160 (2) Cough. Deep breath ent

(1)
Dyspnea, limited breathing

RA =RoomAir

(0)
Apnea

NC = Nasal

140
Blood Pressure
V9 •/-% Cannula• (2) SBP =/- 20 of Pre-op (1) SBP =/- 20-50 of Pre-op120 V/S
(0) SBP =/- 50 of Pre-op
X = A4ine BP Consciousness - = Cuff BP
97
100 (2) Fully Awake. audible

= Pulse crYing ;
(1) Arousable to verbal or pain
80 A TEMP
Color S= Skin
A(` (2) Baseline coior IS appearance 1)...

0 =Oral ..

(1) pale, mottled. jaundiced
60 A= Aidllary
. i'D T =Tympanic Circulation (Peds 5 Years) R = Rectal 40 (2) radial Pulse Palpable
(0)
Cyanotic

(1)
Axillary palpable. not radial

..,/ LOS

(0)
Carotid ordy reliable pulse

C=Cervical

20
TOTALS: Must be 9 or T = Thoracic greater to DIC. otherwise 0 L = Lumbar needs anesthesia approval for
RR S = Sacral
to to 13 D/C, ( 0
T
Patient teaching done . Wound Care. Pain Management,
Time
T. C, & DB,. Incentive Spirometer. Comfort MeasuresPain (0-10) Safety: SR up X 2, Falls Precautions. Privacy Maintained
LOS itoonve on IEVOISel
DATEDEPARTMENTISERVICEICUNIC
D.9-06t03
PA(A)

give: Name —last
. FLOW CHART

fist, middle; grade; date: hospital or make! laakyl . HISTORYIPHYSICAL
.
OTHER EXAMINATION . OTHER ermari OR EVALUATION

.
DIAGNOSTIC STUDIES

.
TREATMENT

Previous edition is obsolete

WAMC OP 173-E, (Revised) 1 Apr 01 (MCXC-DN)
DA FORM 4700. MAY 78 USAPPC V2.00
MEDCOM -21683
DOD-035259

MEDICATIONS
NURSING NOTES
Allergies: Time Pain Medication & Route Pain I/E By
1-10 Dosnne 1-10 104 rt-t0-4AlreL DMZ Sh /4-1D de11 1114 arbl MSO4 cv 69....9.goz 99.
ASok

^^

1111

I I ifi
7a4.4A-

04444.40-66?veAbi,_e
04 It
41- amid/.9lom,114y(4c01( Akt.A PIO JO Pniv. 4n. Sol( 0,•04-.9ehicro.w./ IA Aiwa .
timspq ax w id4lukt?
NEUROVASCULAR"
N
Time Site Range Sensory P Cap T Color Of Refill Motion
k

huotAlti.

6 WA. PK,
Mm Lim i imilhet t r
15' Lieci ti.itea P 6 1.0..... Pk-
t
30. VI I ithita 4' P 6 on, 171G
45'
60'
90'
D/C 14.01 kp. . -c(4 ..k.-to 6 wr". pv..,

Movement/Sensation: + =present,- =absent Temp:C = Cool, W=Warrn Pulses: P = Palpable, D =Doppler, A =Absent Color: C =Cyanotic, Capillary Refill: 13= Brisk, S=S uggish "P = Pale, P"n C-SECTIONS"„...-----Adm 15 41:.-----15' 60' 90' D/C Fund. Height
—.-------.--Lochia Peripasgt/...— ..- t
rrid. Cond.
DRESSINGS Location Type Drainage
Time
Adm"111• 1..-IF% e.3,G14 Vfv1 1)
30'"L-• yei -09( v_Av(44. 0

Ii'
60'
DIC"Ks 5 bl ex, txei 0, 446. O

PACU OUTPUT
Time Source Amount
CARDIAC RHYTHM Time Rhythm Symptomatic? Rhythm Strip Run? tkl" 1"-S oz, 0 o
Discharge Criteria:
Date:22c0-03 Time: (I 5 PARS: /0
BP: 133140 T:cf("HR: a$ RR: /7"Sa02: Cj
Pain Level at D/C (0-10):
Intake:" Output:"
Additional Data:"
Transferred To: !CW
Report Given To:
Transferred Via: W/C"r ev Ambulance
Transferred By:
Cleared IAW Reco ery"B-3
Charge Nurse Signature:

WAMC OP 173-E
MEDCOM - 21684

DOD-035260

'
11311
EN DIA
FEN ALE IF ENI4
RELIGION/ FLELI4
,
I
1
/
I2.UNIT/ UNITE ,I I
.1
FORCE/ELEM ENT NATIONALITY/TIONALIT.E.
AF/AI RIM

-mc-../4"/ freed(JECX 41/j
I DISEASE/ MALAOIE I I PSYCH/ PSYCH I
,
.
K ALERT/A LERT S S. PULSE/ PODIA TIME/ NEUPF
I9
.
PAIN RESPONSE / REPONSE ALADOULC UR I
I

I

IVERBAL RESPONS EREPONSEVERBALE 7 UNRESPONSIVE/SANS REPONSE

Ino/Sm I I NON / ON?‹.1
SPI IMAI OSY / IN114410H1
S. TOURNIQUET/ CARROT
NO/
NON
/71 inYES /OUI
]
CatiDOS E
TIMEI HEURE TIMEI!DERE I
11 .
67/WAIL
47/3‘.›
[ TIME/ BLURS
9. TREATMENT !OBSERVATIONS ' CURRENTMEDICATION,ALLERGIES/NBCIANT1DOTE)"7...
TRAITEMENT/ OBSERVATIONS / PRESENT(MEDICATION/ ALLERGIES / ANTIDOTES
fr9vu,,,t,
4,o(e P I
ca(tbsri,
PD511.4c __„4-ezAd. (A-0(20A,­
rorcL1I
.efp,•-voicc 0
I
DIS POSITION/

I' RETURNEDTO D UTY/RET O UR Acora TIPAE /HEURE 4c.EvAcuATED/ EVACUE OECEASEDOECE DE
I
II. PROVIDER I UNIT/ OFPICIER MEDKALI UNTEt
DAT E/DA TE ETYMA/DOE I
e--
MEDCOM - 21685
DOD-035261
i
t
MEDCOM - 21686
DOD-035262

1. Reporting MTF 2. MTF Loc..-Admission's.. .. Loafing information
.19 (.2) -7, IZ For use of this form, see AR 40-400; the proponent agency is OTSG

0580 IMO
4. Pay Grade 5. Sex FGN M
3. Register Number Name (Last, First, MI)
6. DoB (YYYYMMD 7. Age at Admission 8. Race 9. Ethnicity Religion
1988-03-01 40..../.1 15Y

X 9
11. FMP 12. Social Security Number
10. Length of Service ETS
99

13. Marital Status Hour of Admission Branch / Corps:Organization (Active Duty Only) 20:36
16. Zip Code of Residence:
14. Flying Status 15. Beneficiary Category
K78-PRISONER OF WAR/INTERNEES

19. Trauma Prey. Admission
17. Unit Location 18. MOS
DIS NO

Name / Relationship of Emergency Addressee20. Source of Admission Ward: Address of Emergency Addressee
Direct from ERk.. .A ---)-ICW1
...--V

Telephone Number of Emergency AddresseeName and Location of Medical Treatment Facility:
0580 ; No Install Provided
22. MTF Transferred To 23. Date of Disposition (YYYYMMDD)
21. Type of Disposition
TRF-OTH

2003-11-02

26. Date this Admission (YYYYMMDD)
24. Clinic Svc - Admitting 25. MTF Transferred From
2003-10-19

AEA - ORTHOPEDICS
27. Location of Occurrence 28. MTF of Initial Admission 29. Date of Initial Admission
2003-10-19

,. ,

FOR LOCAL USE ..0- -
--,
Type Patient (Inpatient / Outpatient): Inpatient

Admission Diagnosis Narrative: S/P L FEMUR X-FIX
1 ro. u iNAC?

( L „6 ti 0 Procedure Narrative(s): D lip9, 5-A
\
"--
I 5

Cause of Injury Narrative: i a(..
co 0 Li v "L'

wired) Signature of Admitting Clerk
Admitting Off
Automated Facsimile - DA FORM 2985, MAR 2000
MEDCOM - 21687
DOD-035263
Automated Facsimile •N .TIENT TREATMENT RECORD, -ER SHEET ------7 For use of this form, see AR 40-400, the proponent agency is OTSG
1 Re ister Nb 3. Grade FGN Admission Remarks
4. Sex M 5. Ag 22 1 6. Race X 1 7. Religion : 1 I 8. LnthOfSvc 9. ETS 10. PrevAdm NO ,

11. FMP 99 13. 0 ganization 14. Ward
15. FlyStatus 17. Dept / Ben K78-PRISONER F WAR/INTER 18. BranchCorps 19. UIC / ZIP 20. Type Cal DIS

22. Hour Of Adm: 21 Clinic Service
21. Source of Admission
20:36 ABA - GENERAL SURGERY
Direct from ER
24. Name/Relation of Emergency Addressee 27a. Address of Emergency Addressee 29. Reportin•MIF 1/(7) -7--0580 25. Type Disp TRF-OTH 27b. Telephone No 26. Date of Disp 2003-11-09 28. Date This Adm: 2003-10-19 30. Date [nit Adm 2003-10-19 Admitting0fficer: 732. Units Blood Components
31. Selected Administrative Data Marital Status: In/Out Patient: Inpatient Do MOS: L)-2-
33. Cause Of Injury:
34. Diagnosis / Operations and Special Procedures:
SOFT TISSUE WND

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35. Total Days This Facility Absent Sick Days Other Days / Coop Care Days • %I Sign. _ Officer DAVIS M i A" noon 7aA7 -10f,.. 70 Supplementa Care • • • • • Bed Days Total Sick Days -/ -cords Officer
DOD-035264

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DOD-035275

AUTHORIZED FOR LOCAL REPRODUCTION
MEDICAL RECORD PROGRESS NOTES
DATE NOTES
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PROGRESS NOTES
Medical Record

STANDARD FORM 509 (REV. 5/1999
\40 -1
Prescribed by GSA/ICMR FPMR (41 CFR) 101-11.203(b)(10 USAPA V1.00
MEDCOM - 21700
2A1111
DOD-035276

LAST NAME FIRST NAME MIDDLE INITIAL ID NUMBER
DATE NOTES
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DOD-035277
AUTHORIZED FOR LOCAL REPRODUCTION
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MEDICAL RECORD PROGRESS NOTES
DATE
NOTES
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HOSPITAL OR MEDICAL FACILITY RECORDS MAINTAINED AT
PATIENT'S IDENTIFICATION: (For typed or written entries, give: Name - last, first, middle;
REGISTER NO.
WARD NO.

ID No or SSN; Sex; Date of Birth; Rank/Grade)
PROGRESS NOTES
Medical Record

STANDARD FORM 509 (REV. 5/1999) Prescribed by GSA/ICMR FPMR 141CFR) 101-11.203lb/00/
USAPA V1.00
MEDCOM 21702
-

DOD-035278
LAST NAME FIRST NAME MIDDLE INITIAL ID NUMBER
DATE NOTES
001/02 -P74 Pi-AA?9Ar', . e-S / f-0­0 _ii,,_0 rA . Ls c.:r.9go Es ?//1't-ori 1 /2i_ a cll ',,,-\, rif7.41i c-0---T • • I Av & o_ j,6, (k 6-?_TV 6.-til #A" a. ii 9I, Wilii t
9 (C' ) -

STANDARD FORM 509 (REV. 5/1999) BACK
USAPA V1.00
MEDCOM - 21703
DOD-035279
AUTHORIZED FOR LOCAL REPRODUCTION

MEDICAL RECORD" CHRONOLOGICAL RECORD OF MEDICAL CARE
DATE9 SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry)
PO AE 09234 OPERATION IRAQI FREEDOM BAGHDAD, IRAQ
OCT 2003
REASON FOR VISIT
TIME op
A O_9A._,•.,A_..1-...9 PA. g/ 6 6
HR
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ALLERGIES
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HOSPITAL OR MEDICAL FACILITY 9 STATUS9DEPART./SERVICE 9RECORDS MAINTAINED AT
501 FSB BATTALION AID STATION
SPONSOR'S NAME9 SSN/ID NO.9RELATIONSHIP TO SPONSOR
PATIENT'S IDENTIFICATION:9(For typed or written entries, give: Name - last, first, middle; ID No or SSN; Sex; 9REGISTER NO.9WARD NO.
Date of Birth; Rank/Grade.)
1111.11111111111.M.01111_9¦9i i \9, ,

NAME
RANK CHRONOLOGICAL RECORD OF MEDICAL CARE
Medical Record

SSN
DOB UNIT STANDARD FORM 600 (REV. 6-97)
Prescribed by GSA/ICMR
USAPA V2.00

FIRMR (41 CFR) 201-9.202-1
MEDCOM - 21704
DOD-035280

NSN 7540-01-075-3786

LOG NUMBER TREATMENT FACILITY
EMERGENCY CARE MEDICAL RECORD AND TREATMENT
RECORDS MAINTAINED AT
(Patient'
PATIENT'S HOME ADDRESS OR DUTY STATION ARRIVAL
STREET ADDRESS DATE (Day, Month, Ye ajj TIME 6. _9•
(13 ' 9' ­
3 7

/9(1 6
E": CU
CITY STATE ZIP CODE TRANSPORTATION TO FACILITY
DUTY/LOCAL PHONE MILITARY STATUS .------19:11RD PARTY INSURANCE A.A._ AREA CODE NUMBER ,...„„....__„----ITEM YES ....t_J0:2_,ilt.A.----"--ITEM yES-' NO PRP ADDITIONAL INSURANCE
SEX
,

FLYING STATUS9DD 2568 IN CHART9....- --Z")....., AREA CO9.-14UMBER MEDICAL HISTO9STAINED FROM NAME OF INSURANCE..COMPANY .. __,.. „••• CURRENT MEDICATIONS INJURY OR OCCUPATIONAL ILLNESS _. -EMERGENCY ROOM VISIT WHEN (Date) DATE LAST VISIT 24 HOUR RETURN
J014 PHONE • ----
AGE 1- -----
ITEM YES NO
ri YES9I-1 NO

IS THIS AN INJURY? WHERE TETANUS
ALLERGIES

INJURY/SAFETY FORMS DATE LAST SHOT COMPLETED INTITIAL SERIES HOW YES9NO
CHIEF COMPLAINT
9
/7/

-
CATEGORY OF TREATMENT VITAL SIGNS
...ETIM TIME ..1 }
. EMERGENT9------'?
BP 'N PULSE ' W
liFIGENT
RESP9I-11
...,"9,
0 1--TEMP 97 rf/--
MI NON URGENT
WT
I LAB ORDERS
CBC/DIFF PT/PTT BHCG/URINE/BLOOD/QUANT CXR PA & LAT/PORTABLE C-SPINE
URINE C&S UA MSCC/CATH
BLOOD C&S X CHEM:
X-RAY
ORDE RS

ACUTE ABDOMEN LS SPINE
SINUS HEAD CT
ANKLE R/L
PATIENT'S RESPONSE

ORDERS
ce
07a/v.
0-c 7-ftWei/5
DISPOSITION91 NT/DISCHARGE INSTRUCTIONS
ri HOME ri FULL DUTY 78 HRS.
MODIFIED DUTY UNTIL RETURN TO DUTY

CONDITION UPON RELEASE ADMIT TO UNIT/SERVICE TO WHEN
REFERRED 01110
0 IMPROVED90 UNCHANGED
TIME OF RELEASE I have received and understand these instructions.

0 DETERIORATED
PATIENT'S SIGNATURE

PATIENT'S IDENTIFICATION (For typed or written entries, give: Name -- last, first, middle; ID no. ISSN or other); hospital or medical facility)
EMERGENCY CARE AND TREATMENT (Patient)
Medical Record
ILJ STANDARD FORM 558 (REV. 9 -96)
Prescribed by GSA/ICMR FPMR (41 CFR) 101-11.203(3)1101 USAPA V1.00
MEDCOM - 21705
DOD-035281

NSN 7540-01-075-3786
TIME SEEN BY PROVIDER

EMERGENCY CARE AND TREATMENTMEDICAL RECORD
(Doctor)
TEST RESULTS
WBC Check if read by 0
ABG/PULSE OX RADIOLOGY radiologist
ct
(.3 H/H SUP 02 PH P02 RESULTS 2
ct
to
PLT PCO2 SAT OTHER

DIP
PT EKG INTERPRETATION
MICROAPTT BHCG ETOH GLU
PROVIDER HISTORy/YSICAL
Prl SL) ;
la • Tr 04-6( AA-11P 12A-k (.7e',t,?4_ e frot4-eec
pL,

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V 0, SCAN6N T\w&D- 5k1.
CONSULT WITH TIME ACTION RESI DENT/MEDICAL STUDENT SIGNATURE AND STAMP
PROV IDER SIGNATURE AND STAMP
DIAGNOSIS
c7" I
CP11111111111.
esA.. LA lANd?inodki
!For typed or written entries, give: Name -- last, first, middle;
ID no. (SSN or other); hospital or medical facility)

PATIENT'S IDENTIFICATION
EMERGENCY CARE AND TREATMENT (Doctor) Medical Record
STANDARD FORM 558 (REV. 9 -961
Prescribed by GSA/ICMR FPMR (41 CFR) 101-11.2031b1110) USAPA V1.00
MEDCOM - 21706
DOD-035282
PREOPERATIVE/POSTOPERATIVE NURSING DOCUMENT
MEDICAL RECORD
FOR Use this form. See AR 40-407: the Proponent agency is The Office of the Surgeon General.
2. KNOWN ALLERGIC SENSITIVITIES (e.g.. lodin, Tape, Medication)
. .
1. AGE a NKDA9PCN9LATEX9. IODINE9. TAPE . FOOD
REACTION:
HEIGHT:

3.
PREVIOUS SURGERY9EX NO9[ ] YES (type):
WEIGHT: 135

4.
PROPOSED SURGICAL PROCEDURE:

tr)T1 F9b9
-
I c.1-4 VC-11

5. ADDIT ONAL INFORMATION: (Previoussurgical and medical history) Skin Condition 9 Tobacco9ppd X_vrs Body Piercing cio 9Diabetes (Y)6)9ROM 9ASA/Motrin W 72hrs (Y)ij ETCH • Implants9Respiratory Disease (Asthma COPD) (Y)9Anticoagulants (Y)el) Glasses/Contact (Y)69Dentures9Hypertension (Y)9Herbal Medicines Y9MEDS:
6. PATIENT PROBLEMS AND NEEDS 7. PATIENT GOALS AND EXPECTED OUTCOMES
8. OR NURSING INTERVENTIONS

A. PSy,cHosocIAL (1).9Allow pt. to verbalize freely.
t9Pt. verbalizes any specific anxiety.
A9potential for anxiety related
q. Explain Or environment and answer to: Exhibits relaxed body posture.
questions regarding surgery.

1 ) Surgical Procedure& 4).9Offer comfort measures. (e.g. warm Operating Room Environment blanket. touch). 2) Separation Anxiety 49
Explain all nursing procedures before Chi d
they are done.
3) Surgical Outcomes
14).9Remain with pt. Whenever possible.
Maintain family interface. Parents to

Q.
stay with pt.
t Pt. will be able to breath without
B. AE9ATION (1). Offer to elevate head of litter or offer
Potential for respiratory difficulty during immediate intraoperative pillow.
..9
d97.9nction due to: Observe pt. While awaiting surgery for
phase.
1) Positioning gns of distress.

2) Effects of Anesthesia
Cp. Assist anesthesia during intubatior 3) Medical/Smoking History
and extubation.
C. INTE GUMENT Pt. will exhibit signs of impairment of Q. Utilize pressure preventing devices sin integrity (e.g., reddened areas).
Potential Impairment of Skin on OR table and accessories. In9rity due to: . . Check for proper positioning and , pport to maintain good body alignment.
1) Intraor mmob_ility
2) ESU Pad Placement . Pad pressure points. 3) Positional Aids
. Place ESU ground pad on non

4) EYILs(12Q5i5 T mpromisect skin surface area.
.9

7-5) Pooling_pf Prep Solutions Keep prep fluids form pooling.
9. PATIENT'S IDENTIFICATION: ( For typed or written entries VERIFICATIONS AT HOLDING AREA: give: Name-last, first, middle; grade, data; hospital or medical facility) ID/Allergy Band I Dentures Removed
4C ! H&P ! Contacts Removed I NPO Since ! Jewelry Removed
! UHCG/LMP I Body Pierce Removed 22 -C-80
! Consent/Blood Transfusion
Signed/VVilnessed/Dated
Surgical Site/Consent verified by
Pt./Anesthesia/Surgeon
! Contact precautions (Y) (N)
knk,1 DA FORM 5179, JUN 91 MEDCOM - 21707 Pleviuu91_11L1U11J die 1../t/lete. ! Family/Friend: USAPA VI.0

DOD-035283
6. PATIENT PROBLEMS AND NEEDS CIRCULATION
9Potential for inadequate tissue
perfusion due to:

1) Intraoperative Mobility 2) Positioning 3) Existing Disease
4) Safety Devices
95) Hypothermia

E. NEUROMUSCULAR
CONTROL

E.I. ); 9Potential Impairment of
Mobility due to:
1) Pain

2) Intra operative Hazzards 3) prosthesis
4) Positioning
5) Transfer pt. To/form OR table
_
Potential Discomfort Due to: 1) Length of Surgery 2) Positioning 3) Arthritis
ecial Senses
F.I. 9Diminished visual perception dtleit 9being: 91) pre-medicated
92) W 0 GLASSES
F.2. V 9Potential for Decreased Communication due to:
4_1) Diminished Hearing 2) Language Barrier
F.3. 9Potential Injury due to
Dentures: 1) Upper 4) Caps 2) Lower 95) Crowns
93) Bridges
G. OTHER PATIENT PROBLEMS NEEDS OR Continuation of Above problems/needs.
7. PATIENT GOALS AND EXPECTED OUTCOMES
t
. Pt. will exhibit signs of adequate tissue erfusion (e.g. color, warmth. pedal pulse.
it) pt. will be transferred to OR table without
difficultly.
pt. will be not experience unnecessary
physical discomfort.

1 pt. will be made aware of surroundings
rior to anesthesia induction.
pt. will be transferred safely to OR table.
t pt. will be able to understand instructions.
Minimize danger of injury during intraop period.
OTHER PATIENT GOALS AND EXPECTED OUTCOMES. Or continuation of above goals and outcomes.
8. OR NURSING INTERVENTIONS
O Check foe support stocking or ace warps. if none, checkwith doctors. kp Check that safety straps are correctly applied.
4:1 Offer pillow for under knees. O Place and take down legs from stirrups with stow bilateral motion.
4) Check that rings and all body piercing has been removed.
d Have sufficient people available for
transfer.
4 Insure proper body alignment.
71 Allow patient to lie in position of

domfort while waiting for surgery. Offer support (i,e..pillows. Bath towel. etc) for positioning.

4 Introduce self. keep pt informed as to
where he. she is and what is happening.
I) Inform pt. in which direction to move
and assist if necessary.
Speak clearly and slow)y._

nr 1110

Address pt. from9side. Validate pt.'s understanding of verbal ommunication. O Verify removal of dentures.
OTHER NURSING INTERVENTIONS
OR continuation of above Interventions.

10. OR NURSING NTER ENTION COMPLET E D/ADDITIONAL INTRAOPERATIVE INTERVENTIO NS NOTED.
CPT/A-ni?Med 03
DATE
11. POSTOPERATI • UATION : SKIN INTEGRITY: Bovie Pad Site: t2( Clean and Dry 1:1 Red . N/A DRESSING DRY & INTACT:
LEVEL OF CONSCI USNESS: . A&O . Drowsy9VI Sleepy9. Intubated (N) gEATHING EASY:
LEVEL OF ACTIVI Y: . MOVES A L EXTREMITIES9. Moves Upper Extremities
(N)

. Transferred to Litter With roller due to spinal
12..PREOPERATI E EVALUATION9PREPARED BY 13. PREOPERATIVE EVALUATION PREPARED
BY (Signature and Title)
CI PThtd TIME: 2130 DATE:?/) rIci-C3 TIME: 0 535
MEDCOM - 21708
REVERS OF FORM 5179. JUN 91 I ISAPA VI n

DOD-035284

MEDICAL RECORD INTRAOPERATIV DOCUMENT
"
For use of this form, see AR 40-407, the prow
ency is the office of The Surgeon General.

1. PATIENT TRANSPORTED TO OPER,— IN 9M
2. PATIENT I
9WED AND PR CE

VIA L, I ley
BY an e•C+N-S rl ci VERIFIED BY9 aff7
3. DATE9
TIME PATIENT ARRIVED IN SUITE
4. PATIENT I
ZD Oct 03 0235 TIME9.9 NUMBER

5. PREOPERATIVE EMOTIONAL STATUS
• CALM9gi ANXIOUS9• EXCITED,9II CRYING9
MI ANGRY9• WITHDRAWN9• OTHER (Specify)
COMMENTS:
7,trin hie -ft lade_ OY 1,t-ii d ei-s{ -elnd-Eryti8k
6. NURSING PERSO9EL
:9ASSIGNED
--RELIEF

SCRUB
.9SCRUB

i
ASSIGNED C
RELIEF

CIRCULATOR
.._.9_9...9.9.. __CIRCULATOR i hj t .. ..9_.
7. POSITION AND POSITIONAL AIDS (Specify)
174 SUPINE9II LITHOTOMY9U PRONE9III KRASKE -9LATERAL:9.
LEFT SIDE UP9. RIGHT SIDE UP

COMMENTS: p& bod nil9n rn e rd_ mai afaii ried9Pro Lq biump anew,-9
zi i-ti e
8. SKIN PREPARATION9
IN NO
DONE BY:9.9

HAIR REMOVAL9PM YES9 PREP SOLUTION (Specify) Rettthat 50,-,,.*sej in
OR9 • NURSING UNIT SITE: a /DLITT Leg?-18-Y WHOM .
METHOD:9

II9DEPILATORY9CI RAZOR SITE:9
BY WHOM: U9CLIP
COMMENTS: AM h?-F-r4 ut-9_._.__._._9. COMMENTS: NI 6
publ i4-9 or -rjuid.s
9. LOCATION OF EXTERNAL DEVICES9 .... .

-A
•" •I
.. -" I f"-7://",61:111,mili¦-" _
...--""'"'"''',­
.."
1.-
LEGEND9X Ground Pad9
-- Safety Strap9= = = Tourniquet-. - ,..--. C = Correct I = Incorrect — ' '
First Closing Final Closing
10. COUNTS
Other•• Count . I. Count
SCRUB9 CIRCULATOR

Sponge9in Yes
IIIIIINEIIIIIPM"m
r

Needle Sharp9tk:1 Yes . No Instrument9. Yes gi No L
_ Other9. Yes Z No .. _
11. PATIENT IDENTIFICATION For typed or written entries give: 12.
ELECTROSURGERY DEVICE(S) (ESU) 9Egj YES9. NO
Name - Last, first, middle; Grade- Date; Hospital or Medical Facility;)
I ESU NO:940912Se1053(0s980130
SIMI 19 k)'-'
O GR PAD:9
UND A BRAND
vTieiVb kElvi LOT NO:962 5
22-
E ':'Ll.7. SU NO:
-(1 0 C' ..9.._
----GROUND PAD:9BRAND
._. LOT NO:
. BIPOLAR NO:

DA FORM R1 7Q-1 nrT sty
DEC

• -1" „WHICH IS OBSOLETE. USAPA V1.00
MEDCOM - 21709
DOD-035285

13. PROSTHESIS, IMPLANTS902 YES91 NO9IF YES NAME: ID NUMBER9'Jr TURER
4.5 cortical9 .6 FuLlut Threacie-ci-Corlic ell 9. lioQ plate_92211, 07
214.028 )( 3 Ve Pam X 391 '9
--
1.1 rv'f.^9X3
Pisi F screw Lund it 052. “02_ Small Era Lon g 4 (05Z-6)1 ZO1

.,-,,.
,9 -;•, MEDICATI NS/ORDERS' , :''''-'
,-,- ..--,•:,-N-:-',: 4. , ,,;,:,::
''` :

IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT. BY ANESTHESIA) 9YES • NO "MEDICATIONS/SOLUTION DOSAGE9. TIME METHOD PREPARED BY GIVEN BY
49

. _____ ..„ ; .......... .

Vis ;
MOUND IRRIGATION9csi YES • NO, TYPEIS):
-._....,

i 0 10 CM NS
BOTHER ORDERS
TIME CARRIED OUT BY9•:'
t11 4.
:PHYSICIAN'S SIGNATURE
15. X-RAY IN OPERATI -IF YES, SITE
YES IRI NO
• C.-Air 9291 .ibrto6 9Leq
16. ,9, .-J L ABORATORY SPECIMENS
_
SPECIMEN (S) NAME9 _ _____ __ .
YES9• NO ),11 •t' --
FROZEN SECTION IFS) NAME NAME
YES9¦9NO Ei
CULTURE (C) NAME NAME
YES9• NO [A ... _ ..... _ _ ___ ___
NAME NAME

NAME

NAME NAME 18. DRESSING/IMMOBILIZATION (Specify)
Filk-li5

17. TUBES, DRAINS/PACKING9YES9r! NO ..i.
TYPE/SIZE 1..,, i , 2. . )4 e v )(,S 616 Vinvost.
1s16-vi

SITE 1. 2. 3. . ._ -___
a l(;tt)ex9leg -9. IACASICIv ymt 9ALL,

19. ADDITIONAL INFORMATION .
al,r61., MQ.-Seth fe•A frn.9. LI erte;rai
0 bsery ex ° SG-I
Turtle * sq 94,
2:15-mm 149
D03154.0510
rdect .fri rbc 9PTA "Mk a\ dime If 4 min

20. OPERATION(S) PERFORMED
1. °el F9R.+. 11 b 1 Pb
-
2-. -S--'T h9P. Lo-we.r Lai9. ,9 (.•() —9
21.
PATIENT TRANSFERRED TO TIME METHOD
Prk Mk 05-35 /.1. 1 fer

22.
REG)STERED9URSE SI ATURE . ._ ___

M-i/A INJ
REVERSE OF DA FORM?OCT 87? MEDCOM - 21710 USAPA V1.00
DOD-035286
VITAL SIGNS RECORD
CAL RECORD
-10SPITAL DAY
IIIIMMIN,
DAY 1111MillirirrillIVII
Fl"114111113111MMINNUNIMMERKINIMINIM TEMP. C
40.6 °

TEMP. F
MAIM MEN NM M

3ULSE
40.0 °

105° swims ® mamm
104°
180 39.4 °
INIMM MMOMMMEMM 170 38.9 ° a)
103° MOWN IIMMOMME 0
Cc

160 102° MINNIMMMMOMPIIM 38.3 ° ac
0

101°
150 37.8° Cui
WNW M MEMO
100°
37.2 ° C
1 .1-

140 MMMINIMMOMMEMEN . a
°37.0
36.7° 0

130 99°° MUMNOMMMOUNWSW a)
98.6120 36.1 ° C
98° MINIMMEN BONO=
110 97° MOMENEMMUMMMMM 35.6 °
100 W 35.0°
90 95° MENUMENNNIMMMM
MMMUNIIMMOMUMMM

80
WHIMMIIMMEMEM M

70
MIIMUMEMINMEMMM

60
MENUMMIONNIONN

50 MEMNON M MIN M
40
PANASIEJAMM
'IRATION RECORD
UMMWOMMOSIMMITIN
11111111111111 MINMIIMINMEMINIVOLIMMOIN
WEIGHT ----¦
1111111110101111111,41111110111110
rgrzw"
111111.1
1111111117MMIMMMMI111 M1 WARD NO. REGISTER NO.
0
st,
ASSN or other); hospital or medical facility)

CHENT'S IDENTIFICATION (For typed or written entries give: Name—last, first, middle; ID No.
i f
0
t--1
_,..,
511-119

MEDICAL RECORD
NSN 7540-00-634-4124
HOSPITAL DAY VITAL SIGNS RECORD
POST-
DAY
MONTH-YEAR DAY rill1111111111111111111111
11111111111111111111
111111111111mu
alliiinua
laillin

19 llnia11111111111IMIIIIII
ll...11111111111
HOUR .zz IMMMMal
PULSE TEMP. F
(0)
(*)
180 105° Witelliiiiitill-M TEMP.
104°
ManalignellEalltal 40.6°
170
ingEnninginaligni 40.0°
160
102° 39.4°
150 103° 111110ENIENI11111111111 oc
101° 38.9° .42c°
140 100° Minnammullall111111
IMMIMMINIMMEMME 38.3° I: 130 9 99° 37.8°
120 8.6° ElligleinIMPIIIMMIN 4)73c
98°
37.2° o
37.0° o-110 36.7°

Co

97° 1111111111111111rill
100 36.1°
90 96° INEREINMEINIIIIMI11111
35.6°

80 95° 111111111111M11111111111E111111 Minn IIMMINIffigin 35.0°
70 IMEN11111111 :c' 11111111111111
60 MIIIIIIIIIINIIMETAIMI
50 11111111111111111111111111
40 IIMM 11111111 ESPIRATION RECORD INIelnalleall
Pal11 IR AL PIM 10191
e MriiallialliffailliallEMI
ratigilliallanillallnallIMMUMIMA
=34,n ' NIEM1111111MUI
C31111%imm
illEaliMMINIEBINIII
0
aft IIIIIIML....Illi
9,h911111ralrMIMMI
44 sr

Imilfiliimeliniiiiiiiin
:NTS IDENTIFICATION
: IIIIIIIIIIIIIMMIIIIIMIIIIIIIII
(For typed or written entries give: Name—last
(SSN or other); hospital or ? , first, middle; ID No.

edical facility)?
REGISTER NO.

)
VITAL SIGNS RECORDS
9

MEDCOM - 21712 Medical Record
4TA
DOD-035288

VI I AL

)ICAL RECORD
111¦11111.11111111.1"NMI
HOSPITAL DAY
1111111•11111111111111111111111111111111111111111111111111
DAY DAY
COM
:AR
TEMP. C

HOUR VAID11111114111111111111111111111111P1111111115211M1
TEMP. F 40.6 °
PULSE (*)
(0)
105°
40.0 °

11111111111111MME1111
104°
°

INIM111101111111011111
103°170
38.9 °

180 1111111111111111111111M1 39.4
102°
160 tx
38.3°

IMIN1111111111111111111
101° vi150
37.8°
To

100°140
37.2 ° cr
37.0 °

111111111111111111111M1111

99° seurimmeimmilleramimeminessiermriomx a)
130 siegimm 36.7 °
98.6°
980 .73
120

36.1 °

rdisestionsissua

97°
110 35.6 °
11111111111112111 1MEIMEI t.)
96°100
35.0 °

111111111111111101 1111111111111

95°909
111111111111111111111 1111111111111

80
inr1111111111111111511=11

70
11111111111111M1110111111

60
50
40
'IRATION RECORD
IFINSPRIPIAND

BLOOD PRESSURE
IIIMICE/1111111411111211111111raffill07111111111E1 1=1=11111111111571111111.11191111071111111011111 MI1111111111111111111
HEIGHT:
111111111111MIIMEDSM
tv SUM"
Num itimmummomi
R4-
5
a
U
G
YI

O 1111 WARD NO.
U a REGISTER NO.
.11111

or written entries give: Name—last, first, middle; ID No. TIENTS IDENTIFICATION (For typed
(SSN or other); hospital or medical facility)
VITAL SIGNS RECORDS
Medical Record

STANDARD FORM 511 (REV. 7-95)
-1

Prescribed by GSA/ICMR. FIRMR (41 CFR) 201-9.202
MEDCOM - 21713
DOD-035289

MEDICAL RECORD

VITAL SIGNS RECORD
INNIIIIM9
POST-
pannIMIMMII
MONTH-YEAR
;t41/03111111111.11¦11111¦1¦
PULSE9TEMP. F
(*) rEMIWOMPAMMUMMITIMMWEI
(0)9
105°
TEMP. C

atliaMMEMEMENN
1809 40.6°
104°
ERIEMMENIMMINIEN
1709 40.0°
103°
NIONEMEMINIMENEM
1609 39.4°
0

11111111EMMINITEMINI
1509 38.9° C
101°
102° IIMIIMMEMMEINIMEMIII ENIMMININIIIIIME
a

1409 38.3° rr
1000 0
130 37.8°
99° C 98.6° 120
98° 37.2° 37.0° w
110 36.7°
cw

11111111111111
100 36.1°
96°
97° 1111111IMMIMMENIMINEINIENIIIIIIMENE111111
909 35.6 ° 80 35.0°
95° I1111111111111111111111111111111
70
NEINIMMENEINIMMII
60
IIRinfilIMENINIIIIIIMMINOMMENINEMMEINI
50
40
ESPIRATION RECORD9 ®M®®® ®®® BLOOD PRESSURE 13a
EIRIPILIIIIMILI
2
o9 LIMUSWINAINIIMMUSI
czomplimmiummimummlummu.
I' lanfirramm¦¦¦•••¦¦
aillamalliellellird
IENT'S IDENTIFICATION
111111111111111111111
(For typed or written entries give: Name—last, first, middle: ID No.
(SSN or other); hospital or medical facility) ?
111111
0
REGISTER NO.
WARD NO.

,IW
STANDARD FORM 511 (REV. 7-95) BACK
MEDCOM - 21714
DOD-035290

i i

subeettotnerrtvacy ALA Ul 11/ / SSN/PSEUDO SSN:
LAST, FIRST Ml. t) •-1/ 1 W63 0 (HematoIog) CRC . -Urinalysis . Misc. Serology
RESULT REF. RANGE TEST RESULT REF. RANGE TEST RESULT REF. RANGETEST
4.g-lo.xx 10 Colt* N/A RPR Negative
WBC WA Mono Negative
App
Gill Negative Microbiology
Negative Source
Bili -Ket Negative Gram
Stain • NIA Negative
130-500 x 10' SG Occ Bid-
Pit
verified 20.5-51.1% Bld Negative H. pylori Negative
Lymph
N/A Micro
pH ,..-.
Parasites Negative Malaria
Mono Prot '
Urob 0.2-1.0 0 & P
Bands Eos
Negative Other
Lymph Baso Nit
Leuk Negative Nfici:oscopic Urinalysis
-

Atvp imm
. . . .. •. . -.

Negative

HCG
Morph

RBC
: KAPI DI ,i , t, • .1,.. i .Yi : .i9:9i.1'9. 19'. I SERI/ I_9'!'9l-i99, 9. ki90 ., : UL, ----_
;i9' f -: ¦99-, ,. ¦9
Spun 42,52% 0.,1)9 Ksd.Bink .-.
37.47°.: (F)

Hematocrit
Patient Ti]: In.

19(6)

ITT SF 518 WITH

Sed Rate Tesi Name.
•PT.

T REQUESTED

Test. Result := 14.9 sec..Rat 't 0 = 1.2
Other
calculated INR =.

1.38
.. Coagulation Studies Sample Typexitrated wh. blood.. . .

.Test Date.:11/01/03 , IT OF BLOOD ime.
--
Test Time :06:04.

(.6.-3/

' 'ST RESULT REF RANGE Cal d Lot CROSSAL4TCH
— Operator.
sees 9.8-13.6 (6 (6) ---&
P
, .....-
-
21-34 secs

APTT
IAPIDPOIN1 COAG ANALYZER..

V4.54.
sLRIAL #005485.06:08

11/01/03.

D dimer
to ugAril Patient ID.
FDP VO1
Test Name.­
:t

Test Result:= 31.5 sec.

REMARKS:
Sample Type:citrated wh..

blood.J

.

I.: 11/01/03.
Test Time.

I REPORTED BY: Test Date.
:06:06

1.• -

-.

'arc. Lot
. ;,erator

MEDCOM - 21715
DOD-035291

WardiSeetion: REQUESTIN LAB ...AT • Y RESULT FORM
....) Subject to e Privacy Act of 1974) I LAST, I' TIME SSN ' • • , 2_1•)(Y0 0 Lig S ema ) CBC Urinalysis
-! ' 14 . .-TEST RESULT REF. RANGE TEST RESULT] REF RANGE IIIM RESULT REF. RANGE
WBC 4.8-10.8x 10' 1 Coloi N/A RPR Neeative 1 RBC 4.7-6.1 x 109 1 App • NIA Mono Negative
1-/gb 14-18 g/dt (M) Glu Negative • . igkrobiology12-16 g/(11 (17) Het 42-52% (ti4) Bili Negative Source 37-47% (F) 1¦:4('NI Ket Negative Gram
RAPIDPOI N; I
Stain

SERIAI #01.0 ; SG 'N/A Occ Bld Negative
(0 —1 31d Negative H. pylori Negative
Pationt ID : 0 Test Name : i N/A
Al Micro
TeSt Result::: 18.4 sec.
Parasites

Rat io = 1.5 )rot Negative Malaria
Go 0001009°,101.6....5
Sanpie Type:citrated w . blood Jrob 0.2-1.0 0 & P
Te it Date :11/02/03

Jit Negative Other
Te A Time.-:05:10 Cat -d Lot' 11q -1" euk Negative Wici:escopic Urinalysis
Oporator
TCG Negative
RAPT )P0--COG ANALYZER V4.54
SERI 11/02/03 05:17

Pati 3nt ID: * CSF -Blood Bank
To3t Namekk— -
Te: Et Resu 1 t : = 34.1 sec . :eIl. MUST SUBMIT SF 518 WITH
Sample Type:citrated wh. blood ount EVERY UNIT REQUESTED

:11 CI /-3
Tost Date lirectigen 1 Neszative AB 0/Rh
Tost Time
19 i)-1
Card Lot

-. - Mood Bank Unit Cros.smatch"
Oporator I I'
. (MUST.SUBMIT SF 518 WITH EVERY UNIT OF BLOOD . • , .. REQUESTED) t • TEST RESULT I-REF RANGE (RUT TYPE CROSSML4TCH
1319.8-13.6 secs
,_.
AP` : 21-34 secs
D dimer . 20 ug/ml
FDP 1 10 ug.,dmi
REMARKS:
REPORTED BY: DATE: LAB ID NO.:.
01v-Dv-t1-3-
MEDCOM 21716
-
DOD-035292

WapgSection: REQ • JAN: LAB. ..ATO RESULT FORM (Subject to th Privacy Act of 1974)
I

11,.1,0
---- -DATE TIME SSN :,-II a 1LAS T
O.., I"• _,.."_
_-... (Hemarojob) CBC . . - Urinalysis
LEST RESULT REF. RANGE TEST RESULT REF. RA.NGE TEST RESULT REF. RANGE
WBC 4.8-10.8 x10' ColoT ___ N/A RPR Negative
RBC 4.7-6.1 x 109 App " N/A Mono Negative
Hgb 14-18 gdr(M) 12-16 •'(11 (F) Glu Negative Mkrobiohygy
Hct 42-.52% (.4) ; Bili Negative Source
MCV 3747% (F) 80-94 it (NI) Ket Negative Gram
'APIDPOIN! •I.R 1 AI , ,,i ,, . iit tt 1 _QO fl (TA -..i_; ':.1 ' • ", / H N/A Stain 0-cc Bld Neizative
ciii6ii i!, 19 1.0 — f est tlt.on: lest.Result:. z6.1.
sec. ***RESULT. OUT OF RANOr*** Ned. N/A Negative H. pylori Micro Parasites Malaria Negative
Ratio = 2.3 0.2-1.0 O&P
Calculated INR - 3.86
Sample Type:citrated wit.blood Negative Other I
Test Date.:11113/03
Test.Time.41' .'• ..t9 Negative .Nucioscotric Urinalysis
Card Lot
Operator. (,t,)--7 Negative

;APIWOINI • ANALYZER.

,.
V4.54

:I.RIA 11/03/03 03:56 .Blood Bank
CSF -
.

)atierit ID: 1050
to 0_y MUST SUBMIT SF 518 WITH Test Name.EVERY UNIT REQUESTED
:APTT
Test Result:= 41.5 sec.

gen Negative ABO/Rh
Sample Type:citrated 1. blood I
i

Test Date.
;11/03/0'

• . •:, BloOd Bank Unit Crossinatch
-02 ' S e
Test Time.

MUSTSUBMIT SF 518. wrril EVERY UNIT OFB1,00D .
b I..
Card to , -2.
' -; .'.• REQUESTED)
Operato ,

TEST F AGE DLIT TYPE CROSSMATCH
9.8-13.6 secs
PT
21-34 secs
APTT
20 ugiml
D dimer
I 10 00)11
FDP

I
REMARKS:

1 DATE: LAB ID NO.:.
RF,PORTED BY:
MEDCOM -21717

DOD-035293

RA
SE

Pa

RA
SE

Pa

I Ward/Section: A K EQUESTING PHYSICIAN: LABORATORY RESULT FORM
--C--C VI I (Subject to the Privacy Act of 1974)
LAST, FIRST, Ml. DATE TIME SSNTPSEUDO SSN:
i/k-) . (i(i 10 _
--.. (Heniatoto6) CBC Ucinalysis . Misc.: Serotogy
TEST RESULT REF RANGE TEST RESULT REF. RANGE TEST RESULT REF. RANGE
WBC 4.8-10.8x 10' pp Colot- N/A RPR Negative
RI3C 4.7-6.1 x 109 .i.--) WA Mono Negative
3 IDP iINT UAL n. , , . ;) ; i ;;'•.. Negative Microbiology
tient ID; kg (-‘)-1 Negative Source
Test Name!'" Negative Gram

Test Result:= 42.0 sec. Stain 'N/A Negative
***RESULT OUT OF RANGE*** Oce Bld Ratio . 3.4
Negative H. pylori Negative
Calculated .INR = 7,41 Sample Type:citrated wh. blood MA Micro Test Date.
:11/07/03 Parasites Negative
:05:06.

Test Time.Malaria
19 (C) -1

Card Lot
0.2-1.0 0& P
Operator 40-1-'

Negative
Other

PIDPOINT r ANALYZER V4 .54 Negative
-;Microscopic Urinalysis ' •

RIAL 11/07/03 05:12
Negative

to (0
.....--4--)
tient ID:

:APTT
Test Result:= 81,3 sec.
***RESULT OUT OF RANGE***

Test Name.

. CSF Blood.Bank
Sample Type:citrated wh. blood.
Test Date.

:11/07/03

Test Time.0,)--Y ...41 MUST SUBMIT SF 518 WITH
:05:08
Count EVERY UNIT REQUESTED
Card Lot Operator 19 42 Directigen t Negative ABO/Rh
Coagulation Studies. ..- .Blood•Bnnk Unit Crossmatch . . .. •
• . (MUST.SgMrr SF 518 WITH EVERY UNIT OF-BLOOD . ' ' • - • REQUESTED)
TEST 41 -1 REF. • , . UNIT TYPE CROSSAL4TCH
P-[' t 9.8-13.6 secs
AP'IT : 21 -34 secs •
0 dimer 20 ug m1
F DP i 10 uglunl
REMARKS:
REPORTED BY: DATE: LAB ID NO.: .
MEDCOM 21718
-

DOD-035294

WardiS7re -: REQUESTING PHYSICIAN: LABORATORY RESULT FORM i
,ik, (Subject to the Privacy Act of 1974) LAST, FIRST, M-1 DrITE TIME SSN/PSEUDO SSN: C) L
5--
_


..._.(Heinsi - • Urinalysis . Misc. Serology
TEST RESULT REF. RANGE TEST RESULT REF. K41VGE TEST RESULT REF. RANGE
WBC 1.8-10.8x 10' Coloj N/A RPR Negative
RBC 4.7-6.1 x 109 App N/A Mono Negative

Hal 14-18 gJdt(/v1) Glu Negative : Microbiology ApiE'll IN I , .. :;t;Tt. ':.• I.— '):i — ._. ___ Negative Source
kJYii
Negative Gram

P
Stain

itient IDOPI---,- 401
Test Name , N/A Occ Bld Negative
Test Result:= 36.8 sec.
***RESU OU T OF RANGE*** Negative H. pylori Negative
Ratio . 3.

C9
N/A Micro
Calcula R = 6.52
Parasites

Sample Type :citrated wh. blood
Negative Malaria
Test Date :11/05/03
Test Time • 10 0.2-1.0 0 & P
..--

:ard Lot )perator Negative Other \44) --L Negative roscopiclUrinalysts ' -RA
IMPOINT COAG ANALYZER
V4.54
SEI JAL 1/05/03 G Negative
05:42
Pat lent ID• est Name. 1111----
1
est Result:. 55.2 sec. CSF Blood Bank ...
**RESULT OUT OF RANGE***
ample Type:citrated wh. blood MUST SUBMIT SF 518 WITH

;est Date :11/05/03 .unt EVERY UNIT REQUESTED
est Time :05:39
rectigen 1 Negative ABO/Rh
ird Lot N )/
0aerator

... SloOd Bank Unit Crossmatch '6(07/ . (MUST sown. SF 518 WITH EVERY UNIT OF BLOOD . . -..- REQUESTED) TEST "ULT 1 REF. RANGE UNIT TYPE CROSSAL4TCH
1
PT 9.8-13.6 secs

21-34 secs
20 ug/ml
FDP I 10 ug/ml
REMARKS:
REPORTED BY: I DATE: LAB ID NO.:.
MEDCOM - 21719

DOD-035295

RAPID
SERIA

Pat iel
Tes
Tes

**4
Rat
Cal
Sam
Te
Te
Cal
OpE

RAPI
SERI

Pati

W ar di SegAIL41: _ 1 KtiVULJ
4-010 , LAST, FIRST, Na.—
t--, \A j
•-• (Hematology) CB
TEST ! RESULT REF RANGE
1 WBC ' 4.8-10.8 x 10'
RBC 4.7-6.1 x 109
th,l,
¦ 4
'0 NT I.,, ! : 'i . ! I , 11 .. 4 \
It ID: alli,L_ k9 (1) 1
t Name :*r'--t Result:. 41.3 sec. RESULT OUT OF RANGE** i0 = 3.4 culated INR = 7.21
ple Type:citrated gh. blo d ,, t Date :11/06/03
\O 1°)-1/
T Time :05:29 d Lot rator 1)--Z
' G ANALYZER V4.54
)POI ' 11/06/03 05:37
AL
9 (4)4-1
ent ID:
Test Namell.--------est Result:: 67.7 sec.
-
*RESULT OUT OF RANGE* *
Siimple Type:citrated .q st Date :11/06/03 S--t T i ine .111E'. :94
C ird Lot 0perator oagu
1Nti MI 1C-JA IN::

I DATE 1 ( QN
-Urinalysis
LABORATORY RESULT FORM '

I (Subject to the Privacy Act of 1974)
TIME- SSN/PSECDO SSN:
oy-io
. Nlisc. Serology _

TEST Coloi App . il 1u 4 ',.et
!Ci I Id 1
-0t. 7013 t a ',G
. blood
iInt
RESULT REF. RANGE TEST RESULT REF. RANGE
N/A RPR Negative
NlA Mono Negative
Negative '
Negative
Negative
/A OccBld Negative
Negative H. pylori l;eraive
N/A Micro
Parasites
, Negative Malaria
0.2-1.0 0 & P
Negative Other
Negative Microscopic Urinalysis
Negative
_
CSF - Blood Bank ,
MUST SUBMIT SF 518 WITH
EVERY UNIT REQUESTED

(-().----1----ctigen 1 Negative ABO/Rh • tudies. . BloOd Bank Unit Croismitch . . . (MUST SUBMIT SF 518 WITH. EVERY UNIT OF BLOOD . .. REQUESTED) :
'ST R45:14.T.H.-R-P.--/r NGE L7v7T TYPE CROSS:114T(711
PT
APTT
D dimer
FDP
REMARKS: 1 REPORTED BY:
r9.8-13.6 secs
21-34 secs
20 ugimi
10 ug n1
:
_J-
1 DATE: LAB 1D NO.:.

MEDCOM -21720
DOD-035296

MEDICAL RECORD - ANESTHESIA
For use of this form, see AR 40-66; the proponent agency is the OTSG
y DRUG"(Units)
TOTALS TOTAL EBL
ig
= D .i z -c. ) 10.9, / •CeZ;:ifrieb
Fi/k4;47^I Vi..-, ( /41(­
S t.:D

cc cc -0
•(,/,. (ice_)
c1L-9 t7) . 41 -2--0 I
0 a 2,., P. of ,,..7.,-" ("71 ) ,Z a:
,lc, 0 z /_'= "TOTAL URINE
ct i.7. -zy"(41 ") /OD "
AK"
1- ( pt4P-0
rc gc.70?•
z -.)-1-
W u) Ev, (?)
oz VOLAT ., kr21,6 del -..f.-Er.)
9 / •/-65.--.3'O ;•C-,C1 -.•‘10 .".° -1'"P
24V t it? FLUIDS - SUMMARY
D " AGENT
• 0 Z 12-ii % e.t.
CRYSTAtOID• ...6

1= 1- (i L AIR L/Min
w Z t •
X 0 En N20 L/Min
COLLOID-
(4 02 L/Min / -

O
w , Z-Z.-7..--V -2-----—
SINGLE DOSE DRUGS-MARK ON GRID ....
z BLOOD-

WITH NUMBERS & ENTER IN REMARKS
LINE site
w . Warmed Mi.
REMARKS

r5 . Warmed
5 I WEIReil ../MCV. -..""-------,ifiepey '---
Code drugs with numbers,

_.1 El Warmed
events with renters

LL
. Warmed
EST BLOOD LOSS

LOSSES
.......

UR NE -...------ ,,_.-----,.„..------­
'-------,. -LC'
P YS STATU ,,0
TIME•ittin..,/c - ''
,. 36 ,., ,-,c
.,, - --46.
t
AtElitCP
-,___I. .1—
SYMBOLS: , , 9
roDy WEIGHT. .9
220
'

r. BP by cuff
LB 200 . ,

v
'---: 180 , , . , .
II II
HEMATOCRIT:
A ' , , .
Heart rate . , ,

160 ; ;
, i . ,
INITIAL DATA: •

Resp rate 140 „ — i . i J j T=1 I if
BP-
ce 3 120 ,
WWI 41125/3
HR-BR 1
4Einglir
(transduced) 101:k ,
ERW
1... i" . f S*

9 ------

EQUIP ECK 80 -:!---
. ---41-0-

T 0 Y
' • '-4.--,,i-T-6ZaiL-r-AU-.
OK?-Y N TOURNIQUET 60 _I_ _I_ -',---1-- / : /J.__L-J
PATTEN RECHECK T-21/
Ir .
40" -, AA A
OK for ill A A I A TA A .• Ad, 11/17A7V44AA
PROCEDU
ANES- X-X V
20 MN
--`-l-
PROC-0_0
TIME-i . , 1—
. . . -T---r--r —I—T „'”'
VT - ml
2e0 f9s to9-• to -;--op 2,vo .19,0 14-qP 9
1-f - breaths/min -j
/ • 1 6----i _..5 1?(0 ?Po
ut
W Peak inf pres / PEEP

MODE - Slponl. AIssist), C(011) --G-/21. ? Z-1 , ...S. - 7
_., - ....--
? RECOVERY ATI657.3!S-
BP/Auto Cuff ET CO2 (tor() Illb 07-, -•--7 7
-,5r 67.1-?_ ..-7,-6"F S-
U/ PACU ICU Specify)
w F102 (Frac or %)
1..._ , g-3 • ;710 11 Et • 'il' ' --77 *17i--­
cC ,--• Li) 01,2) .,„' :-,
SpO2 (%) i OTHER
CO ECG

0
• CONDITION: TEMP-site
IL - .6 K. ;:-Cl._ 6 9----ifZ,
I ---
0 9 RESP-/0 SpO2•
O N-M Block IT/4)

BP-9HR-
-77

9
to ANESTHESIA /PROCEDURE
CC
TIMES •

0
F-

m Start Room End
u,

2
Warming blkt z
0 02.. 24) CIZ
2 Cony warmer ../ arf 5 Mer, with letters & symbols,?EVENTS_, o Ready Begin End
o

explain under REMARKS?Position?'''" 0 —1
u_ OLV.010 03°
PR EDURES and CPT Codes:
ANESTHETIC TECHNIQUES:
Describe block technique under Remark's
¦?Alq/-,/qci,./ (711:4;= G-A' -
PATIENT IDENTIFICATION:
Typed or written eentries: Name, Grade/Rate, .
AlWAY MANA_GEME ;:_IntubaCrn roe,?e technique,?commleest,4 6.,,, ....A T.,
utblad ?techni?Medical facility 1.f - 0/--9‘'),-...-9• ""O m, I a?irS-.7-9Z.-
v,,,,..}9, .G-,-:,9.,,,, -z,--/9fraL,
Cii -9/3/57699

Pill11111, 61 A9
- PROCEDURE
LOCATION: 0‘2-•
--z...
DATE:
PAGE ( OF

rivi \f?. ci--nier-
I-1 A rrtonn -r-rctel coo •tr.r.n.
COPY 2 -ANESTHESIA PROVIDER9 USAPA V1.00
DOD-035297
ANESTHESIA PLAN 0 RE PREPROCEDURAL ASSfSSMENT (SedatiokiAnesthesia)
Age dD_DAYS MOS

Sex (--KMALE ( ) FEMALE'
, .SA Physical Stat 2345'E1
PROPOSED PROCEDURE:
WT:
SURGICAL SERVICE:
NPO SINCE: ALLERGIE :
HABITS:
PREOPERATIVE
TOBACCO:

PAST MEDICAL HISTORY/SYSTEMS REVIEW ASSESSMENT ETOH:
Cardiovascular: PAST SURGICALJANESTHETIC
DRUGS: Hypertension I N Y "
Angina"I N 1.Y "
CURRENT MEDICATIONS:

MI" N Y 9
( ) = ordered as premed

CVA \ N Y Other"\NJ Y
) Pulmonary System:
( ) Asthma N Y
( ) Bronchitis/URI N

,,,..1 pHYSICAL EXAMINATION

( ) COPD N Y
BP 1,454-IR ,k13 R"T_____

( ) Other (CO,
-
Pain Scalb 0-10 -

( ) Renal System:
HEENT-Teeth "

Acute/Chronic RF N Y
Trachea 1Y

PREMEDICATIONS: Gastrointestinal: TMJ/Neck
None Y (f4,"/CC
Hepatitis N Y Oropharnyx yvtem"PO Hiatal Hernia N Y NaresPO PUD/GERD N Y CHEST: ?c
mg"0
Endocrine System:
Diabetes

CARDIAC:
(Lcc) p

LABORATORY STUDIES: Steriods Y Thyroid EXTREMITIES:
HB/HCT:
Neurological:
U/A:

Seizures IV Access: C)OTHER: Neuropathy N Ulnar Filling: "
Other N Y Gynecological :
BACK:

Pregnancy N Y Other Significant Hx: OTHER:
NY
NY
"
Familial HX N Y
NPO Since "

ANESTHETIC PLAN: ) LOCAL { } MAC"
{ } Regional (Specify): "
INFORMED CONSENT/COUNSELING STATEMENT: Plans, alternatives and risks of anesthesia including death have been explained to and
discussed with the patient/legal guardian.
The pati
Auestions answered. Signed:
Dam: " "
° Time: "Z. Hrs
ESIA EVALUATION AND NOTE ti)14
SEDATION KEY:
RENT ANESTHETIC COMPLICATIONS
1. MINIMAL (Anxiolysis) Patient responds normally to verbal commands
Signed: " Date:
Time:"Hrs 2. MODERATE (conscious sedation) Patient responds purposefully to
\04)
verbal commands alone or

Patient Identification: (Ward) accompanied by light tactile stimulation. Airway assistance is not necessary.
3. DEEP SEDATION/ANALGESIA. Patient responds purposefully following repeated or painful
4frilM 1111111111v-q0-ki
stimulation. Airway assistance-may be necessary.

4. ANESTHESIA. Patient does not respond to painful stimulation.
WAMC Form 2300 (Revised) 15 Mar 01 MCXC-DOS
Previous edition is obsolete

ANESTHESIA RECORD
'U.S. GPO: 2001-629-183/40002

MEDCOM - 21722
DOD-035298

FISH 7540-01-165-7294
519-301
RADIOLOGIC CONSULTATION REQUEST/REPORT
(Radiology/Nuclear Medicine/Ultrasound/Computed Tomography Examinations)
EXAMINATION(S) REQUESTED
AGE SEX SS
WARD/CLINIC REGISTER NO. •
ft&
((ANTI--

U/s 9 FILM"4) -1 TELEPHONE/PAGE NO.
1111111111,02)-z
DATE REQUESTED.
cD,SoC_TCA3

SPECIFIC REASON(S) FOR REQUEST (Complaints and findings)
(

e
71.ea Le-%-CZ-7 ae_Pj (6, --0144,g5
C C FiAFv
PATIENT'S IDENTIFICATION (For typed or written entries give:
Name — last, first, middle, Medical Facility)
LOCATION OF R AGILITY
1111, epo
SIGNATURE
ATION STANDARD FORM 51943 17877
MEDCOM - 21723"
Prescribed by GSA/ICMR FPMR (41 CFR) 101-11.806-8

DOD-035299

CLINICAL RECORD - DOCTOR'S ORDERS
For use of this form, see AR 40-66, the proponent agency is OTSG THE DOCTOR SHAL RECORD DATE, TIME AND SIGN EACH SET OF ORDERS.
IF

PROBLEM ORIENTED MEDICAL RECORDSYSTEM IS USED, ITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
PATIENT IDENTI CATION DATE OF ORDER
NURSING UNIT ROOM NO.
PATIENT IDENTIFICATION DATE OF ORDER C.4'))
/17 ,56
17)
PATIENT
IDENTIFICATION
DATE OF ORDER
NURSING UNIT
PATIENT IDENTIFICATIO
TIME OF ORDER LIST TIME ORDER NOTED AND
HOURS SIGN

fz5. /c AJ
s-n,)3 cc

TIME OF ORDER ,04
(02:7r2- Ali" 90 U 2-,9Z-Ale k
HOURS

DATE
ORDER n

TIME OF ORDER
..-0.
A
LrY

NURSING UNIT
REPLACES OF 1 JUL 77, WHICH MAY BE
DA 4256
, FAO/47179
MEDCOM - 21724
DOD-035300

CLINICAL RECORD - DOCTOR'S ORDERS
For use of this form, see AR 40.66, the proponent agency is OTSG
THE DOCTOR SHALL RECORD DATE, TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECORD
SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW

.

PATIENT IDENTIFI CATION
DATE OF ORDER
DIME OF 09211 2) LIST TIM E ORDER
NOTED AND
22
zs2-23

-
HOURS
SIGN

c--zsa ?5 ‘--966 "'N-Yi
L6-Yel--/,;3-e"(-) 1-)
NURSING UNIT ROOM Na BED NO.
.
04 ° i&t Vl
PATIENT IDENTIFI CATION
DATE
HOURS

NURSING UNIT ROOM NO. PATIENT IDENTIF1 CATION BED NO. DATE OF ORDER TIME OF ORDER HOURS
NURSING UNIT ROOM NO. PATIENT IDENTIFICATION BED NO. DATE OF ORDER TIME OF ORDER HOURS

NURSING UNIT ROOM NO.
BED NO.
REPLACES EDITION OF 1 JUL 77. WHICH MAY BE USED.
DA 4256
, FAcrR1 9
MEDCOM - 21725
DOD-035301
• CLINICAL RECORD - DOCTOR'S ORDERS
For use of this form, see AR 40-66, the proponent agency is OTSG
THE DOCTOR SHALL RECORD DATE, TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECORD SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
PATIENT IDENTIFIC TION DATE OF ORDER" LIST TIM
TIME OF ORDER
ORDER OTED A

45r. A2,..f9 HOURS SIG
ig-To

b6
C62,?
123
c2­

NURSING UNIT ROOM NO. BED NO.
PATIENT IDENTIFICATION DATE OF ORDER" TIME OF ORDER
Q3"1K:el?) HOURS
b 4)e¦ -2_,•E) E by 4. 0/4/ UaY c, /17),t)O 3,
NURSING UNIT
c-W/c?577.o
PATIENT IDENTI DATE OF ORDER TIME OF ORDER
" HOURS
NURSING UNIT ROOM NO.
BED NO.
PATIENT IDENTIFICAT ION DATE OF ORD R"TIME OF ORDER
" HOURS
NURSING UNIT ROOM NO.
BED NO.
REPLACES FneTioN OF 1 JUL 77 wHicH MAY BE USED.
DA1FAOPRRM79 4256
MEDCOM - 21726
DOD-035302
CLINICAL RECORD - DOCTOR'S ORDERS
For use of this form, see AR 40-66, the proponent agency is OTSG

THE DOCTOR SHALL RECORD DATE, TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECORD
SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.

PATIENT IDENTIFICATION
DATE OF ORDER
TIME OF ORDER LIST TIME ORDER NOTED AND
1 ).....7., T
HOURS

l'S A"Ztj a) SIGN
0l , (,?i, - - ? ,g)„(-a--izs?1.y)4/'?;;Crv7'. ;
it
i
NURSING NIT ROOM NO.
C2 034 C./1.
PATIEN IDENTIFICATION
DATE OF ER
TIME OF ORDER
HOURS

___,---
to 0 7-'
. (")_.,)•.k9
NURSING UNIT ROOM NO. BED NO.
PATIENT IDENTIFICATION
DATE OF ORDER
TIME OF ORDER
HOURS

NURSING UNIT ROOM NO.
BED NO.
PATIENT IDENTIFICATION
DATE OF ORDER
TIME OF ORDER
HOURS

NURSING UNIT ROOM NO.
BED NO.
FORM
REPLACES EDITION OF 1 JUL 77, WHICH MAYBE USED.
1A 79
MEDCOM - 21727
DOD-035303
THERAPEUTIC DOCUMENTATION CARE PLAN (NON
CLINICAL RECORD MEDICATION)
For use of this form, see AR 40-407; -
Mo. ( TkYr. 2003 INITIAL PROPER COLUMN FOLLOWING EACH COMPLETION
ORDER CLERK! RECURRING ACTIONS, DATE COMPLETED
DATE NURSE FREQUENCY, TIME

11151PMERMINERIBLIPIII
Mall-111 11111111111111111111
ISINIT°1 OG
.1111111111111111111
IGO
V3 rat

001111=1111111111111111111FM

ao
co
P1

a:A.1Kr= OC)esT-C
ECM
cDOC9cx TA-evvot_4(_, )LE rl
JPI
AMP 6 titglitalimmummiaNalia
-?1111¦¦¦¦¦¦¦¦¦¦¦ 11111
IIIMMIIIIIIIIIMMI.11111111111111111111111111111111111111111
1111M111111111111111 11¦41111111111111111111111111111111111111111111•11111
¦¦¦¦¦¦¦¦¦¦¦¦¦¦¦
¦¦¦¦¦¦¦¦¦¦111¦¦¦M1
¦¦¦¦¦11¦¦¦¦¦¦¦¦¦
EOM
PRIMARY DIAGNOSIS: ADDITIONAL PAGES IN USE: El YES El NO
ri.btq, sip _6 (A)
-
PAGE NO'
PATIENT IDENTIFICATION:

ACTION TIMES USE PENCIL. CIRCLE ACTION TIMES D 8 9 10 11 12 13 14 15 E 16 17 18 19 20 21 22 23
:

N 24 01 02 03 04 05 06 07 — DA FORM 4677, 1 OCT 78 EDITION OF 1 Me 77 MAY RA I ism
USAPA V1.00
MEDCOM - 21728
DOD-035304

Verit y by
Initialing THERAPEUTIC DOCUMENTATION CARE PLAN

(NON-MEDICATION)
Order"Clerk Mo Yr 2003 Nurse SINGLE ACTIONS Date to Time
Date"
lime to be Done be Don, Time Done Initials
+?)
2 2co
zoo

To
oQ__ '7,2)ri( kfri
( Fe, 20D 9r 14.
aa-1.2c5D
0 '50

Order/
Clerk/
Explr PRN
Nurse IN177AL PROPER COLUMN FOLLOWING COMPLETION
Date ACTION, FREQUENCY •
TIME/DATE COMPLETE)
USAPA V1.00

MEDCOM - 21729
DOD-035305
4,191(1,3

CLINICAL RECORD THERAPE TIC DOCUMENTATION CARE PLAN (NON-MEDICATION)
For use of this form, see AR 40-407;the proponent agency Is the Office of The Surgeon General. MO. 11 Yr. 2003
VERIFY BY1NITIALING 111, INITIAL PROPER COLUMN FOLLOWING EACH COMPLETION
ORDER CLERK/ HR"
RECURRING ACTION, DATE COMPLETED
DATE MIEMIP'
NURSE
FREQUENCY, TIME
ZIM

ups Lib oad-Ole8 NVAeD
,

Rt,E co
ocT •"8ir
PT-1 P7T 6) X Icicu-4 • r

A111111111111111111.11¦
ALLERGIES: f= YES E3 NO
PRIMARY DIAGNO ADDITIONAL PAGES IN USE:
1-7 YES n NO

PAGE NO' "
PATIENT IDENTIFICATION:"( c

.-G9 (k1126tvli
emi 6
ACTION TIMES USE PENCIL. CIRCLE ACTION TIMES D 8 9 10 11 12 13 14 15 E 16 17 18 19 20 21 22 23 N 24 01 02 03 04 05 06 07
MEDCOM - 21730
PI A C/%011/1 A C77 A 17/77.
70 EDITION OF 1 DEC 77 MAY BE USED.
I le A SLI M AA

DOD-035306
Verity by
THERAPEUTIC DOCUMENTATION CARE PLAN • Initialing ( NON-MEDICATION)
Mo y,92003

order Clerk
Date to . Time to
SINGLE ACTIONS
Date be Time Done Initials
be Done Done
1
'''''',,,...................„„............

/ZIO W 40/& . ¦*4-Zrifli /...e,)11, 9441/
Order/ ateDate Clerk/ Nurse PRN ACTION, FREQUENCY INITIAL PROPER COLUMN. FOLLOWING COMPLETION TIME/DATE COMPLETED
— – – – – – –
– – – – – – – – '
...
– ,m, .... Elm ¦,1 .wa .N. um.
..." .... .... ... ...
..“.¦ ft.. w¦ or. w.w w.. ¦
¦ .... ¦.. ¦ .... ¦ ¦

USAPA V1.00

MEDCOM - 21731
DOD-035307

THERAPEUTIC DOCUMENTATION CAR E PLAN (MEDICATIONS)
CLINICAL RECORD For use"of this"form, Sea AR 40-407;
the proponent agency Is the Office of The Surgeon General.

MO. 10 Ynta

VERIFY BY INITIALING ,. INITIAL PROPER COLUMN FOLLOWING EACH ADMINISTRATION
ORDER CLERK/ RECURRING MEDICATIONS, HR DATE DISPENSED
DATE NURSE DOSE, FREQUENCY

11111111111 -.3e v /
F

111M1111MagEniii
Ki.
.13.94

, 9.. .
„cryt_e_" LCA
Li2L,L)Isocc-_,,1 vIr__.
H-1-vviratakinrj fc writ
ko al--Ar1Ce9A--
Er

U2----fulvAry1 C-i r1 ,a/DTT
____ ivc: op, I

align=
1 I 1119 1111111M/NIWIIM
AO NIIMPAS101MAW
_
No

PSa

1___
I
ALLERGIES
J YES 0 NO PRIMARY DIAGNOSIS%
ADDITIONAL PAGES IN USE: DYES Ej NO

(5 31Er OL l b i R tO SIP C-61") PAGE NO
PATIENT IDENTIFICATION:
DISPENSING TIMES USE PENCIL. CIRCLE MED TIMES
-19 .
D"7"8"9"10"11"12"13"14 E"15"16"17"18"19"20"21"22 N"23"24"01"02"03"04"05"06
• AIA
EDITION OF • r`"' " t"" •

's EXHAUSTED.

MEDCOM - 21732
DOD-035308
Verify by
THERAPEUTIC DOCUMENTATION
Initialing
(MEDICATIONS) .
IMo..
Yr

Order Clerk/ Data Nurse SINGLE ORDER, PRE•OPERATIVES Date to Time to be Given be Given
Time Given Initials

CC(' .
0C., 1-04e4,V3 1 oft
c9-0,ilt,i____________
9410,103
L
.

i
Order/
Exalt' Cl erk/" PRN INITIAL PROPER COLUMN FOLLOWING ADMINISTRA77ON
Dote Nurse"ME , CATION, DOSE, FREQUENCY

TIME/DATE DISPENSED
-1. ^i
I ih 5°Lk"2— "n'Ar
DA 15
1 4720
.--J—' \-) e"Q l -2_ hfs
,96 garyt7y-01 cozy171- 1-2rD ep4---c9-02,6 /-r
1 -otr-coc-4- I-Zi941-466 Dir)dm 22cc ,-946-vAnn,, -27ce..01
ociAozsbc1-z6c0--26xr
, 1. ;Mb )71r I/ ,9P P"' 130 V' ll53-"0-07P -1
15' kt I 0
air.
--.

MS0+ 2.1= 1
i
1(
Pek-C,j(-Z fa i_E c'ezi' '

iza a
.,..., ,.,
b)
6)V ---Z' ° JW-A-i r -
U.S. GPO: 1990-454-110/95216

MEDCOM - 21733
DOD-035309
1V- Tint, 21,\TDIr0
1"THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS)CLINICAL RECORD For use of this form, see AR 40-407;the proponent agency is the Office of The Surgeon General. Mo. V Yr.A5
VERIFY BY INITIALING . INITIAL PROPER COLUMN FOLLOWING EACH
11¦•¦•11 ADMINISTRATION
ORDER CLERK/ RECURRING MEDICATIONS, HR DATE DISPENSED
DATE NURSE DOSE, FREQUENCY
t '"__
, -0 00r

-2 MCIrl

dringln 67
--"ditCocci D P
9-9-dLiAlo,e1A_ (()0 . (,

av afF A-y\cel- _4-9I IPS cp
I •

80 ()Or .9A k,t1-6-{/04,1, -t,,A. aZi "to
-
"--1\IPD Y •4¦Minin 1111
0, f W.21-.1"Pi"/"t"o0 ir 14-'-:"iiia °
11W,it ae.iirfe

_a 11.M1pj1/111•IMImgmem amp! Ili cm, ow
&.")
611

1 .4g; -a ....
•P
P,INNIFArn
I

la 0)) —Z
I

ALLERGIES- El YES
O NO PRIMARY DIAGNO
A DDI TIO N AL P AGES IN USE: DYES ONO

likljt1 bl
1) SpoSTNI
PAGE NOPATIENT IDENTIFICATION:

DISPENSING TIMES
ISO \P (0 I"

USE PENCIL. CIRCLE MED TIMES D"7"8"9"10"11"12"13"14 E"15"16"17"18"20"
19"21"22 N"23"24"01"02"03"04"05"06
r% A"FORM • WWI -b 1 FEB9 EDITION OF I r'lLis 7, "'" oe •'"'" • "
EXHAUSTED.

MEDCOM -21734
DOD-035310
Verify by
THERAPEUTIC DOCUMENTATION CARE PLAN Initialing (MEDICATIONS) Mo..E Yr.
Order Clerk/
Date to Time to
SINGLE OR DER, PRE.OPERATIVES
Dote Nurse Time Given Initials
be Given be Given
C:CA-.1:(-) OCT"\ Cfr'INiQVCO3
0111114-6
0 (‘
Order/
INITIAL PROPER COLUMN FOLLOWING ADMINISTRATION
Clerk/ PRN TI
Expi Nurse MEDICATION, DOSE, FREQUENCY
Dater TIME/DATE DISPENSED
U.S. GPO: 1998-454-110/95216

MEDCOM - 21735
DOD-035311
MEDICAL RECORD-SUPPLEMENTAL MEDICAL DATA
for use of ibis tom. see AR 40.65; the pros'onent spines, ¦ S for Olb,, of lb, Swim". General OTSG APPROVED Ward Post-Anesthesia Care Unit (PACU) Flow Sheet
1

SEPOR'l TITLE
Drains Ajrv_y.ia
Dale: :rime In: Allergies: Pre -OP V/S: Procedures Anesthesia Type (Circle)): General Spinal Epidural ryyjo IV Sedation erve Block OR Intake: Crystalloid 6 Colloid 1..) OR Output: UOP "T -EBL r/w• tel-( Meds/Times: Hemovac NG JP ‹.1" ETT Trach Other
TLS
Histor

Pre Os Mrds
Infused

Time Site By
Solution f Amount

SEM
emmo Time
QS
Sa02
FiO2
Methods
240
220 Post-Anesthesia Recovery score
Codes

ADM 30' D/C
Criteria AIRWAY
200 Activity
(2) Moves 4 Extremities A= Ambu Moves 2 Extremities BB = Blow-by
2_

180 (0) Moves 0 Extremities M =Mask
FT =Face

Airway
(2) Cough. Deep breath Tent
160 (1) Dyspnea, limited breathing RA= RoomAir

(0) Apnea NC =Nasal Cannula
140 Blood Pressure
(2)
SBP 20 of Pre-op

(1)
SBP 20-50 of Pre-op VIS

(0)
SBP =/- 50 of Pre-op X= A-line BP

120
=Cuff BP

Consciousness
= Pulse

100
crYin9

(2)
Fully Awake, audible

(1)
Arousable to verbal or pain TEMP

S =Skin

80 Color
12) Baseine color a appearance

0= Oral

(1) pale, mottled, jaundiced A = Axillary 60 e• (0) Cyanotic 2--T =Tympanic

R = Rectal

Circulation (Peds v 5 Years)
(2) radial Pulse Palpable
40 (1) Axiltary palpable, not radial LOS

(0) Carotid only reliable pulse C = Cervical T =Thoracic
20 TOTALS. Must be 9 or L = Lumbar
greater to O/C. otherwise needs anesthesia approval for
S= Sacral

RR
DIC,
T Patient teaching done; Wound Care. Pain Management.

Time T. C. F. DB,. Incentive Spirometer. Comfort Measures
Pain (0-10) Safety: SR up X 2. Falls Precautions. Privacy Maintained

an Me on reverse

LOS DATE
I

DEPART MEMIEEICLINIC
PREPAR lAsnat
• C_

Name —last,
(.,
law entnesire:
FLOW CHART

PATIENT'S IDENTI . HISTORTIPHYSICAL .
lest, middle: glade: date: hospital or medical
. OTHER is•mre
OTHER EXAMINATION OR EVALUATION
.
DIAGNOSTIC STUDIES
.
TREATMENT
.

Previous edition is obsolete WAMC OP 173-E, (Revised) 1 Apr 01 (MCXC-DN) USAPPCS12.00 DA FORM 4700, MAY 78
MEDCOM - 21736
DOD-035312

MEDICATIONS
NURSING NOTES
Time Pain 1-10 Medication & Dmtane oute Pain 1-10 , I IE By Ty3c pke,i)e)?051z4
L-91? f4-1,1k61 ir 71-

0.6 L
Ls—A?

sp)2 / ) Lips -11111111
NEUROVASCULAR
(1+: -
eITINNLVS
Time Site Range Sensory P Cap T Color
Of Refill i 1_0 9!44
Motion
Adm itraim '14 L 1 MF
--r-to maluralm_.(
m
15."aqi-v-7-0
imuraur
30' ily.ARIP ----14
45' VAIVIEMEL
60'
90' MI

DIC INELIKIMMININERIMUMIlle
Movement/Sensation: + =present.- = absent Temp:C = Cool,
W =Warm Pulses: P = Palpable, D =Doppler. A =Absent
Color: C= Cyanotic.
Capillary Refill: B = Brisk. S =S uggish P = Pale, Pk = Pink

C-SECTIONS
.---------....„ Adm

15' 30' 45' 60' 90' D/C
Fund. Height

Lochia
Peripad#
Fund. Cond.

DRESSINGS
Location Type

Time Drainage
Adm Z(..o 3J+ c.,;_s-f-151.,

it...____
30' sc,c,i-e„.s---1-
60'

FRERMNIMINIIMIII."—
,
t -z

PACU OUTPUT
Time Source Color/Appearance
Amount Discharge Criteria: Date:'2-Irt-53Tims: bt.p BP: In
HR:

Sa02:C14-Pain Lev l at (0-10):
Intake:

ut: (eCZ) Additional Data:
CARDIAC RHYTHM
Transferred To:
Time Symptomatic? Rhythm Strip Run/

Rhythm
Report Given To:

?AU NO VIER
Transferred Via­

• Ambulance Transferred By:
Cleared IAW Recover(
Charge Nurse Signatur WAMC OP 173-E
MEDCOM - 21737
DOD-035313

Doc_nid: 
3951
Doc_type_num: 
77